**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #283) received treatment and care in accordance with professional standards of practice and physician orders. The facility admitted Resident #283 to the facility with diagnoses including Diabetes and Hypertension. However, the facility failed to monitor the resident for signs/symptoms of hyperglycemia/hypoglycemia, and failed to monitor the resident's blood sugar level while the resident resided in facility. In addition, the facility failed to obtain the resident's heart rate/blood pressure as ordered by the physician on 06/18/2021, and per the facility's COVID-19 protocol. On 06/18/2021, nursing staff assessed Resident #283 to be ashy in color and cool/clammy to touch, although staff contacted the physician and sent the resident to the hospital, staff failed to obtain the resident's glucose level. On 06/27/2021, Resident #283 would not talk to staff and the facility contacted Emergency Medical Services (EMS) to transport the resident to the hospital. However, there was no evidence the facility obtained the resident's blood glucose level before transferring the resident, even though the resident was assessed to be sweaty, weak, and non-verbal. Review of EMS documentation revealed when they arrived to the facility the resident was diaphoretic (sweating), weak, and would not speak. EMS personnel obtained the resident's blood glucose level, which was 26 mg/dl, administered the resident Dextrose intravenously, and transported the resident to the hospital. Review of hospital records revealed the hospital admitted Resident #283 to the Intensive Care Unit (ICU) and diagnosed him/her with Acute Metabolic Encephalopathy secondary to Hypoglycemia. The facility's failure to ensure residents received treatment and care in accordance with professional standards of practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/16/2021 and was determined to exist on 06/17/2021 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 07/16/2021. An acceptable Allegation of Compliance was received on 07/23/2021, which alleged removal of the Immediate Jeopardy on 07/21/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/21/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, revised April 2011, revealed the purpose of the policy was to prevent recurrent hyperglycemia/hypoglycemia, to help residents control their diabetes, and to recognize, manage and document the treatment of complications commonly associated with diabetes. According to the policy complications associated with diabetes included lethargy, restlessness, weakness, pale/cool, moist skin, decreased awareness/senses and loss of consciousness. Interview with the Director of Nursing (DON), on 07/16/2021 at 3:00 PM, revealed the facility did not have a policy related to professional standards of practice. However, the DON stated staff monitored residents with Diabetes for signs/symptoms of hyperglycemia/hypoglycemia, and documented that monitoring in the resident's medical record. Continued interview with the DON, on 07/16/2021 at 3:00 PM revealed the facility did not have written policy related to specifically obtaining vital signs in the facility. However, the DON stated the facility's procedure was to obtain the resident's blood pressure, heart rate, pulse rate, temperature, oxygen saturation and lung sounds every four (4) hours for fourteen (14) days after admission or re-admission into the facility due to COVID-19 monitoring. Further interview with the DON, on 07/16/2021 at 3:00 PM revealed the facility had no written policy on following physician orders when residents returned from a Hospital or Emergency Department (ED) visit. However, the DON stated staff should always follow physician orders when providing care/treatment to residents. Review of Resident #283's medical record revealed the facility admitted the resident on 06/17/2021, with diagnoses including Myalgia, Myocardial Infarction, Hypertension, Diabetes Mellitus and Coronary Artery Disease. Review of Resident #283's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a brief interview for mental status (BIMS) score of fifteen (15), indicating the resident had no cognitive impairment. Review of Resident #283's admitting physician orders dated 06/17/2021, revealed staff were to administer the resident medication for the management of the resident's diabetes including Amaryl and Metformin Extended Release, both of which were medications used to treat Diabetes by lowering blood glucose levels. Although, the resident's admitting orders revealed there were no physician orders to check the resident's blood glucose level on a routine basis, on 06/18/2021 staff obtained physician orders to check Resident #283's blood glucose level every six (6) hours as needed. Further review of the resident's admission orders revealed the resident also received the medications Norvasc and Lisinopril (used to lower blood pressure), and Isosorbide Dinitrate and Toprol (used to lower blood pressure and heart rate). However, the admitting orders did not contain, and the facility did not initiate specific instructions for staff on when to obtain the resident's blood pressure and/or heart rate since the resident was taking the medications. However, per the facility's COVID-19 procedure, staff would be monitoring Resident #283's vital signs every four (4) hours for fourteen (14) days. Continued review of Resident #283's medical record revealed on 06/18/2021 at 11:52 AM, Licensed Practical Nurse (LPN) #3 documented Resident #283 was complaining of back pain. The LPN documented the resident's vital signs were blood pressure 122/68 mm (millimeters) HG (mercury) (normal range 120/80 mm HG), heart rate was 44-50 beats per minute (bpm) (normal range 60-100 bpm), respirations 16 per minute (normal range 12-16 per minute), and temperature 97.6 degrees Fahrenheit (normal 98.6 Fahrenheit). In addition, LPN #3 documented the resident was ashy in color, and the resident's skin was cool, and clammy to touch. LPN #3 contacted Resident #283's physician, who ordered staff to send the resident to the hospital for further evaluation and treatment. However, there was no evidence found to indicate that LPN #3 checked the resident's blood glucose level prior to Emergency Medical Services (EMS) transporting the resident to the hospital. Interview with Licensed Practical Nurse (LPN) #3, on 07/15/2021 at 1:20 PM, revealed she did not check the resident's glucose level on 06/18/2021 when she assessed the resident to be ashy in color and had cool/clammy skin, because she did not consider that a sign/symptom of hyperglycemia or hypoglycemia. Review of EMS documentation for Resident #283, dated 06/18/2021 at 11:41 AM, revealed the facility called and reported a lethargic patient, which needed transportation to the hospital. At 11:59 AM EMS was at the facility and assessed the resident's blood pressure to be 79/54 mm HG, heart rate was 101, and the resident's blood glucose was 300 mg/dl (normal range 70-130 mg/dl). In addition, the EMS record revealed EMS personnel administered 250 ml of normal saline intravenously (IV) in route to the hospital, to treat Resident #283's low blood pressure. Review of Resident #283's hospital record for 06/18/2021, revealed the resident's vital signs on arrival to the Emergency Department (ED) were blood pressure 93/52 mm HG, heart rate was 86 bpm, respirations were 20 per minute, and the residents body temperature was 98.0 degrees Fahrenheit. Continued review of the hospital record revealed the resident's blood glucose level was 256 when evaluated in the ED. According to the record, ED staff administered an additional two-thousand ml's of normal saline to the resident in the ED, because the resident's blood pressure continued to be low with readings of 81/51 mm HG at 1:00 PM and 94/53 mm HG at 2:01 PM. The ED record also indicated Resident #283 was transferred back to the facility on [DATE], with orders to hold the resident's blood pressure medications and to check the resident's blood pressure at least twice a day for the next 2-3 day. Further review of Resident #238's medical record, revealed Resident #238 arrived back to the facility on [DATE], and review of resident's Medication Administration Record, revealed the facility did not administer the resident Isosorbide Dinitrate, Norvasc, Lisinopril or Toprol medications on 06/19/2021 and 06/20/202. However, there was no evidence found to indicate the staff obtained the residents blood pressure at least twice daily as ordered per the ED physician. In addition, there was also no evidence staff obtained the resident's vital signs every four (4) hours as required by the facility's procedure for new/re-admitted resident's per the facility's COVID-19 protocol. Continued review of Resident #283's record revealed the facility only obtained the resident's blood pressure four (4) times during the next (3) days. On 06/19/2021 at 1:32 AM, the staff obtained and documented the resident's blood pressure as 122/60 mm HG. On 06/20/2021 at 2:37 AM, staff obtained the resident's blood pressure and documented it was 126/80 mm HG; and twice on 06/21/2021 at 4:06 AM and at 11:51 PM staff obtained the resident's blood pressure and documented it was 124/79 on both occasions. In addition, review of Resident #283's medical record reveled no evidence that staff ever obtained or documented the resident's blood pressure, heart rate, pulse rate, temperature, oxygen saturation and lung sounds every four (4) hours as required per the facility's COVID-19 procedure. Continued review of Resident #283's medical record revealed for 06/27/2021 at 9:15 AM, revealed LPN #3 documented the resident would not speak to staff and the resident's skin was pink, warm and dry to the touch. The staff notified Resident #283's physician who ordered staff to transport the resident to the hospital for further evaluation and treatment. However, there was no evidence in the resident's medical record to indicate that staff checked the resident's glucose level when the resident was not responsive to staff. Interview with Licensed Practical Nurse (LPN) #3, on 07/15/2021 at 1:20 PM, revealed she did not check the resident's glucose level on 06/27/2021 when she assessed the resident to be non-verbal, because she did not consider that a sign/symptom of hyperglycemia/hypoglycemia. Review of EMS documentation for Resident #283, dated for 06/27/2021, revealed they arrived to the facility and was at the resident's bedside at 10:03 AM. EMS noted the resident was diaphoretic (sweating), weak, and would not speak. Further review of EMS documentation, revealed facility staff told EMS personnel they thought the resident was acting out because he/she wanted to go home. However, at 10:14 AM, EMS personnel obtained the resident's blood glucose level, which was 26 mg/dl. According to the EMS record, they administered 100 ml's of normal saline fluid and 25 grams of Dextrose 50% to treat Resident #283's critically low blood glucose level. Review of Resident #283's hospital record, dated 06/27/2021, revealed the resident presented with a chief complaint of hypoglycemia. According to the hospital record, EMS personnel had administered the resident one (1) ampule of Dextrose 50 before the resident arrived to the hospital. Continued review of the record revealed the ED physician determined the resident had acute Metabolic Encephalopathy secondary to Hypoglycemia. In addition, the hospital record revealed the resident's blood glucose level continued to drop to abnormally low levels after arrival and the resident required an intravenous dextrose drip (used to increase blood glucose levels) and was admitted to the Intensive Care Unit (ICU). Further interview with LPN #3 on 07/15/2021 at 1:20 PM, revealed she admitted Resident #283 on 06/17/2021. However, the LPN acknowledged she had not placed the monitoring of the resident's vital signs every four (4) hours as required by the facility's procedure on the resident's Medication Administration Record (MAR), or the resident's Treatment Administration Record (TAR) or any other place in the resident's record to ensure staff obtained the vital signs as required. In addition, LPN #3 stated she also failed to document on the resident's MARS/TARS for staff to monitor the resident for signs/symptoms of hypoglycemia/hyperglycemia since the resident was a diabetic. In addition, LPN #3 stated she also should have documented on the resident's MARS/TARS to obtain the resident's vital signs every four (4) hours per the facility's COVID-19 protocol. LPN #2 stated the nurses were responsible to ensure they obtained and documented resident vital signs, but would not say why she had not included the blood glucose and vital sign monitoring on Resident # 283's MARS/TARS. Interview with Minimum Data Set (MDS) Assessment Nurse #2, on 07/16/2021 at 4:00 PM, revealed staff who admitted the resident to the facility was responsible to implement diabetic monitoring and COVID-19 vital sign monitoring for new admissions on the resident's MAR/TAR. The MDS nurse stated she was not sure why this was not done for Resident #283. Interview with the facility's Pharmacist on 07/16/2021 at 4:25 PM, revealed she expected staff to obtain physician orders to monitor diabetic resident's glucose levels routinely, especially if the resident was a new admission and was receiving a hypoglycemic medication. The Pharmacist also stated it was a standard of practice to obtain a resident's blood pressure/heart rate before administering any medication that may increase or decrease the rates, stating, even if it's just one medication, especially when the resident was new to the facility and staff were not familiar with the resident. Interview with Physician #1, on 07/15/2021 at 3:00 PM, revealed he was the resident's physician at the facility, but was not familiar with the resident prior to being admitted to the facility. The physician stated he would have expected staff to monitor any newly admitted diabetic resident's blood glucose levels at least twice daily to see how the resident's blood sugar ran, especially when medications were administered which would affect blood glucose levels. In addition, the physician stated staff should monitor vital signs per the facility's COVID-19 processes and obtain the resident's heart rate/blood pressure before administering medications that would affect the resident's heart rate/blood pressure, especially if the resident was new to the facility. Continued interview with the Director of Nursing (DON), on 07/16/2021 at 3:00 PM, revealed staff should have obtained Resident #283's vital signs every four hours as outlined in the facility COVID-19 process, and staff should have followed directions given by the ED physician on 06/18/2021. She also stated staff should have implemented diabetic monitoring on Resident 3283's MAR/TAR, which included assessing the resident for signs/symptoms of hyperglycemia/hypoglycemia. The DON also stated the nurse should have obtained Resident #283's blood glucose anytime the resident displayed signs/symptoms of hypoglycemia/hyperglycemia. However, the DON acknowledged the staff had not received training related to specific care or treatment of diabetic residents. In addition, the DON stated staff should obtain a resident's blood pressure and/or heart rate when administering medications that lower or increase the heart rate or blood pressure. Interview with the Administrator, on 07/16/2021 at 4:55 PM, revealed staff should have been assessing Resident #283's vital signs as directed in the facility COVID-19 process. She also stated she would have expected staff to assess the resident's blood glucose levels and would have expected them to obtain vital signs before administering medications that affect their heart rate/blood pressure. The Administrator also stated staff should follow acceptable standards of practice when providing care to residents in the facility. **The facility implemented the following actions to remove the Immediate Jeopardy on 07/21/2021: 1. The facility discharged Resident #283 to the hospital on [DATE]. The resident has not returned to the facility 2. The Social Services Director (SSD) and Minimum Data Set (MDS) Nurse completed an audit on 07/15/2021 to review the past 30 days of new admissions to ensure the baseline care plan included an accurate summary of the resident's medications. The facility gave the resident/representative a summary of the baseline care plan. 3. The [NAME] President (VP) of Operations and the Regional Quality Manager (RQM) educated the Administrator and Director of Nursing on 07/17/2021 regarding the regulatory intent of F-655. Specific training included instruction that the facility must develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person- centered care of the residents that meet professional standards of care. The baseline care plan must be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to care for a resident properly, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services and social services recommendations. The training also included the fact that the facility must provide the resident/representative with a summary of the baseline care plan that includes, but not limited to the initial goals of the resident, summary of the resident's medications and dietary instructions, and any services or treatments the facility would administer. 4. On 07/17/2021, the Director of Nursing (DON) provided education to the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses on base line care plans including the above information. A post-test with a score of one-hundred percent was required. 5. On 07/19/2021, the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses educated all other licensed nurses, including agency nurses, on the facility's baseline care plans procedures above. A post-test with a score of one-hundred percent was required. 6. Any new licensed nurses, including agency, hired would receive the baseline care plan training prior to providing care and assuming duties. 7. Beginning 07/17/2021, the DON and Nurse Unit Manager reviewed all new admissions to validate that the baseline care plan included an accurate summary of the resident's reconciled medications, and ensure the facility provided the resident/representative with a summary. The DON and Nurse Unit Manager corrected any issues at time of discovery. This would continue for a minimum of 8 weeks. A licensed nurse and/or MDS nurse would review with the resident/responsible party the baseline care plan within 48 hours of admission. A post-test with a score of 100% was required. The baseline care plan remains a working document until the comprehensive care plan was developed. 8. The facility discharged Resident #75 home on [DATE]. 9. On 7/17/2021, the MDS staff completed an audit to verify residents identified at risk for elopement had wander guard bracelets in place and the care plan was accurate with updated information reflecting the resident's status. 10. On 07/17/2021, the VP of Operations and Regional Quality Manager provided education to the Administrator and Director of Nursing regarding the regulatory intent of F-657. Specific education included staff must complete a comprehensive care plan within seven days after completion of the comprehensive assessment. The training also included that the interdisciplinary team (IDT) would prepare the care plan, review and revise after each assessment, including both the comprehensive and quarterly assessments, and as needed. Examples include but were not limited to the need to revise a care plan when a resident presented with exit seeking behavior, or the exit seeking behavior increases. 11. The DON then provided the above education regarding care plans and F-657 to the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director and MDS staff on 07/17/2021. A post-test with a score of one-hundred percent was required. 12. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director or the MDS staff provided the training to the facility's licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 13. Any new licensed nurse, including agency, hired would receive the comprehensive care plan training prior to providing care and assuming duties. 14. Beginning 07/17/2021, the Director of Nursing, Unit Manager, or assigned on-call weekend nurse that served as clinical nurse manager would audit and visually inspect all resident's determined to at risk for elopement to verify the resident has a wander guard bracelet in place and it was functioning. In addition, they would verify the resident's care plan was updated and accurate to reflect the resident's status. Staff would correct any identified issues at the time of discovery. This would continue for a minimum of eight weeks. 15. Beginning 7/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of exit seeking behavior and validate the staff have assessed the resident and that staff had updated the care plan accordingly. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager would do this on weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 16. Resident #283 discharged to the hospital on 6/27/2021, and has not returned to the facility at this time. 17. On 7/16/2021, the Director of Nursing audited each resident's medical record to ensure staff documented resident vital signs, including blood sugar and blood pressure in the record as ordered or per policy. They identified no additional concerns for additional resident assessment. 18. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-684. Including the fundamental principle that quality of Care applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Included in Quality of Care, but were not limited to monitoring blood sugar as ordered or as indicated with signs/symptoms of hypo/hyperglycemia which may include, but not limited to excess sweating, excess hunger, shakiness, increased thirst, weakness, dry mouth; obtaining vital signs as required by facility protocol and/or physician orders. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. 19. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-684. A post-test with a score of one-hundred percent was required. 20. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-684 to facility-licensed nurses,including agency. A post-test with a score of one-hundred percent was required. 21. Any new licensed nurse hire, including agency, would receive this education related to F-684 prior to assuming duties. 22. Beginning 7/17/2021, the Director of Nursing, MDS staff , RN Wound Nurse and/or the assigned Unit Manager reviewed each resident's medical record to ensure that vital signs,including blood sugar and blood pressure, were documented in the record as ordered or per policy. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. Staff would correct and identified issues at the time of discovery. This process would continue daily while the facility remains in immediate jeopardy. 23. Beginning 07/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of a change in resident condition that would warrant obtaining blood sugar or additional vital signs, and validate this/these were obtained. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager completed on the weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 24. On 07/16/2021, the Administrator and Maintenance Director completed an audit to assess all facility exit doors for proper functioning/alarming. They identified no additional doors as having function issues. 25. On 7/16/2021, the Maintenance Director and Assistant adjusted C-Wing exit door magnet lock to ensure alarming during fifteen second egress, and re-set the key code to the physical therapy exit door to work without issue with the wander guard sensor. 26. The contracted service vendor completed a general inspection/service, on 7/20/2021, of facility doors. They identified no concerns. 27. On 07/17/2021, the VP of Operations and RQM educated the Administrator and DON regarding the regulatory intent of F-689. Specifically the facility must ensure the resident environment remained as free of accident hazards as possible; each resident received adequate supervision and assistance devices to prevent accidents. This included identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. Example included, but not limited to identifying the supervision needs of a resident identified as an elopement risk; maintaining and/or modify interventions if supervision needs was still required; revising the care plan with interventions to monitor the resident; assessment of exit doors for proper functioning/alarming. 28. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-689. A post-test with a score of one-hundred percent was required. 29. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-689 to facility-licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 30. Any new licensed nurse hire, including agency, would receive this education related to F-689 prior to assuming duties. 31. On 07/17/2021, the Administrator educated the Maintenance staff to check door alarms twice daily to ensure doors are alarming when opened. This included checking the emergency egress and validating the alarm sounds upon door release, utilizing a wander guard sensor for applicable doors to ensure the magnetic lock responds to lock the door, and inputting the door code to ensure the alarm sounds when the wander guard sensor passes the doorway. Staff would complete this daily while the facility remains in immediate jeopardy. 32. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-760 specifically the facility must ensure residents were free of any significant medication errors. The errors may include issues with the prescriber's order; manufacturer's specifications regarding preparation and administration; accepted professional standards and principles that apply to professionals providing services. Examples to prevent medication errors includes, but not limited to validating medication lists received for residents from home health agencies etc. with family/responsible party to ensure accuracy; reconciling medication lists received for residents and reviewing with physician for administration orders. 33. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-760. A post-test with a score of one-hundred percent was required. 34. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F760 to facility-licensed nurses, including agency. A post-test with a score of one hundred percent was required. 35. Any new licensed nurse hire (including agency) would receive this education related to F-760 prior to assuming duties. 36. The facility held an ad hoc Quality Assurance Process Improvement (QAPI) meeting on 07/16/2021 to review the Immediate Jeopardy citations and discuss the development of the action items to be completed. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Admissions, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director per phone. The team adopted the plan. 37. The facility held a second ad hoc QAPI meeting on held 07/20/2021 to review the status of education and audits. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director via phone. **The State Survey Agency validated the removal of Immediate Jeopardy on 07/21/2021 as follows: 1. Review of a discharge form dated 06/27/2021 revealed the facility discharged Resident #283 from the facility. Interview conducted on 07/30/2021 at 12:27 PM with the DON, revealed the facility discharged Resident #283 from the facility on 06/27/2021. 2. Review of audits dated 07/15/2021, revealed the Social Worker (SW) and MDS Nurse #1 reviewed all new admissions in the past thirty days to ensure the baseline care plan included an accurate summary of the resident's medications, and with a summary provided to the resident and/or resident representative. Interviews conducted on 07/29/2021 at 2:15 PM with MDS #1, and at 2:35 PM with the SW, revealed they had completed the audits on 07/15/2021, for all new admissions in the past thirty days. Review of audits dated 07/15/2021, revealed the Social Worker (SW) and MDS Nurse #1 reviewed all new admissions in the past thirty days to ensure the baseline care plan included an accurate summary of the resident's medications, and with a summary provided to the resident and/or resident representative. 3. Review of an in-service roster dated 07/17/2021, revealed the [NAME] President of Operations (VPO) and RQM provided an in-service for the DON and Administrator related to the development and implementation of a baseline care plan for each resident. [TRUNCATED]