Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent an elopement for one (1) of four (4) sampled residents, Resident #1. On 9/17/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of six (6), and was identified by the facility as an elopement risk, was assisted out of the front door by a Dietary Aide (DA) who thought she was a visitor. She remained outside the facility for approximately 35 minutes, during which the DA left the facility parking lot at approximately 8:50 PM. Resident #1 was found at 9:05 PM knocking on the front entrance door. The facility's failure to provide supervision placed Resident #1 and other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 9/17/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 9/23/25 at 2:00 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 9/18/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 9/19/25 prior to the SA's entrance on 9/22/25. Findings include:A review of the facility's policy, Elopement/Unsafe Wandering Plan, dated February 7, 2012, revealed, .It is the policy of this facility to protect the resident from harm while providing care in a manner that helps promote quality of life in a safe environment.Definitions.3. Elopement-Elopement occurs when a resident leaves the premises or a safe area without authorization. A record review of the facility's investigation revealed on 9/17/2025, at 9:00 PM, Certified Nurse Assistant (CNA) #1, identified that Resident #1 was not in the common area or in her room when she returned from her lunch break. The Registered Nurse/Minimum Data Nurse (RN/MDS) was in the facility and was notified that Resident #1 was not on her side of the building. The RN/MDS nurse immediately called a Code W (elopement) and initiated a search of the building and perimeter. CNA #2 found Resident #1 who was knocking on the front door at 9:05 PM while searching in her assigned area; Resident #1 was dressed appropriately for the weather and had her purse on her shoulder. Resident #1 was escorted back into the building with no issues of distress noted. The Administrator and the Director of Nurses (DON) were notified of the incident. The RN/MDS completed a body audit with no signs or symptoms of injury. The RN/MDS completed a head count of all current residents in the facility, and all residents were accounted for. She also notified the medical provider and Resident Representative (RR). The Administrator arrived at the facility and checked that all doors were functioning properly. The root cause analysis determined by the Administrator and DON found that Resident #1 followed a dietary employee while he was leaving at the end of his shift. It was determined through interviews that the dietary employee was unaware that Resident #1, was a resident and was under the impression that she was a visitor. A record review of the admission Record revealed the facility admitted Resident #1 on 9/16/25 with current diagnoses including Wernicke's encephalopathy and vascular dementia. A record review of the BIMS (Brief Interview for Mental Status) Interview MDS, dated 9/16/25, revealed Resident #1 had a BIMS score of 6, which indicated her cognition was severely impaired. A record review of the local weather report revealed on 9/17/25 from 7:55 PM to 8:55 PM, the temperature was 83 degrees and clear.On 9/22/25 at 8:30 PM, during an observation of the facility and surrounding area, the facility is located approximately 925 feet from a four-lane highway and is situated within an industrial complex with multiple surrounding commercial buildings. A wooded area borders the south side of the property. The facility grounds include a paved parking lot with designated spaces for staff and visitors, and sidewalks providing access to the front entrance. Multiple exterior lights were observed around the building perimeter, including at the front entrance and doorways. There are no fencing or restricted barriers observed between the facility grounds and the surrounding industrial area.On 9/22/25 at 9:15 PM, during an interview with CNA #1, she confirmed that she was assigned to Resident #1 on 9/17/25. She reported that she last observed the resident sitting in the main lobby prior to leaving for her scheduled lunch break at approximately 8:30 PM. CNA #1 stated that when she returned from break around 9:00 PM, Resident #1 was not in her room or in the lobby. She immediately notified the RN/MDS nurse and other staff that the resident was missing, and a facility-wide search was initiated. At approximately 9:05 PM, CNA #2 located Resident #1 knocking on the facility's front door. CNA #1 confirmed that she was aware the resident was care-planned as an elopement risk, with 15-minute checks in place and identification in the wander book. She stated the facility followed its elopement policy, secured exits, and ensured all residents were accounted for. She further reported that after the incident, she was included in an in-service on elopement prevention and policies.On 9/22/25 at 9:25 PM, during an interview with CNA #2, she stated that on 9/17/25 while working on her unit, staff realized Resident #1 was not accounted for. CNA #2 explained that at approximately 9:00 PM, CNA #1 asked if she had seen Resident #1. When she confirmed she had not, the facility immediately implemented its elopement policy and all staff began searching the building and grounds. CNA #2 reported that she was aware Resident #1 was identified as an elopement risk in the wander book and wore a yellow bracelet. She began her search in the main lobby and near the front entrance of the facility. While checking that area at approximately 9:05 PM, she heard knocking at the front door. Upon opening the door, she identified Resident #1 outside the facility. She confirmed that the resident was appropriately dressed for the weather, carrying her purse, did not appear injured or distressed, and was safely escorted back inside. CNA #2 revealed that following the event, she observed the RN/MDS nurse complete a body audit and headcount of all residents. She further reported that she later participated in a staff in-service regarding the facility's elopement policy and procedures.On 9/23/25 at 11:20 AM, during an interview with Dietary Aide #1, he revealed that on 9/17/25, after completing his dietary shift, he clocked out and went to leave the building. He explained that he did not know the exit code, so he went to a nurses' station to obtain it. After entering the code at the front door, he exited the facility. At that time, an individual followed closely behind him and opened the door as he exited. Dietary Aide #1 reported that he did not recognize the person as a resident, as she was dressed in street clothes appropriate for the weather and was carrying a purse. He assumed she was a visitor leaving at the same time. The employee revealed that once he entered his father's car, both he and his father observed the woman attempt to get into a parked vehicle in the lot. When she discovered the car was locked, she returned to the facility's front entrance. He confirmed that later he learned that the individual was Resident #1. He stated he had previously received annual training on elopement prevention and resident identification but admitted he did not initially recognize Resident #1 as a resident due to her appearance and belongings. Following the incident, the employee confirmed he received re-education on the elopement policy, door security procedures, and how to identify and respond if a resident attempts to exit with staff or visitors.A record review of the Employee Time Cards revealed on 9/17/25 Dietary Employee #1 clocked out of the facility at 8:27 PM.On 9/23/25 at 1:32 PM, during an interview, the RN/MDS confirmed that on 9/17/25, at approximately 9:00 PM, she was informed that Resident #1 was missing from her unit. She immediately called a Code W (elopement). All staff secured the doors, conducted a head count of all residents, and began a facility-wide search. At approximately 9:05 PM, Resident #1 was located at the front door, knocking to be let back inside. The RN/MDS stated that following the event, she notified the Administrator and Director of Nursing (DON). Once all residents were accounted for, the resident's physician and RR were also notified. Resident #1 was assessed and had no injuries. She was observed to be dressed in a gray short-sleeved shirt, brown shorts, and sandals, with her purse on her shoulder and sunglasses on top of her head. The RN/MDS further explained that Resident #1 had previously been assessed as an elopement risk, and her name and information had been placed in the elopement books located at each nurses' station, the kitchen, and therapy department. She also wore a yellow elopement-risk bracelet. Following the incident, the resident's care plan was updated with new interventions.On 9/23/25 at 1:50 PM, during an interview with the Administrator, she confirmed that on 9/17/25 at approximately 9:00 PM, staff identified that Resident #1 was missing, and the MDS nurse immediately initiated a Code W (elopement). Staff secured all doors, conducted a head count, and began searching the building and perimeter. At approximately 9:05 PM, the resident was found knocking at the front door, appropriately dressed and without distress. A body audit revealed no injuries, and the medical provider and responsible representative were notified. The Administrator stated she verified the doors were functioning, interviewed involved staff and residents, and initiated in-services for all employees on elopement procedures before their next shift. The incident was reported to State Agency (SA) and the Attorney General's office, and an emergency Quality Assurance Performance Improvement (QAPI) meeting was held to implement corrective actions. These included door quality checks, alarms on exits, elopement drills on all shifts, wander assessments on all residents, and audits of care plans and elopement books. She further explained that the root cause analysis determined the resident had followed Dietary Aide#1 out of the building, as the employee mistakenly assumed the resident was a visitor.On 9/23/25 at 1:50 PM, during an interview, the Director of Nursing (DON) confirmed that on 9/17/25 she was notified by the Administrator and RN/MDS that Resident #1 had been found outside the facility, knocking on the front door. The DON stated that the RN/MDS verified all residents were accounted for and notified the resident's physician and RR. Resident #1 was assessed with no injuries noted and was observed to be appropriately dressed in a gray short-sleeve shirt, brown shorts, sandals, with her purse on her shoulder and sunglasses on top of her head. The DON further confirmed that Resident #1 had previously been assessed as an elopement risk, with her name and information placed in the elopement books located at each nurses' station, the kitchen, and therapy department. The resident also wore a yellow elopement-risk bracelet. Following the incident, the resident's care plan was updated with additional interventions.The facility submitted a corrective action plan as follows:9/17/25 at 9:00 PM, CNA#1 noted that Resident #1 was not in the common area or in her room when CNA #1 returned from her lunch break. CNA #1 reported to MDS Nurse #1 that Resident#1 was not in the common area or in her room. MDS Nurse called Code W (elopement), and all staff began a search of the facility and perimeter.9/17 /25 at 9:05 PM, CNA#2 was searching in the front of the building where the conference room and business office are located and heard Resident #1 knocking on the front door. Resident#1 was brought in with no signs of distress, only stating she was lost. Resident#1 was clothed appropriately with her purse on her shoulder. The weather was clear skies and around 75 degrees.9/17/25 at 9:10 PM, Administrator was notified by MDS Nurse about the incident. The Administrator notified the Director of Nursing (DON) of incident.9/17/25 at 9:18 PM, MDS Nurse completed body audit with no signs or symptoms of injury.9/17125 at 9:30 PM, MDS Nurse completed a head count of all current residents in the facility, and all residents were accounted for.9/17 /25 at 9:40 PM, MDS Nurse notified Resident #1 's representative of the incident.9/17/25 at9:45 PM, Medical Director (MD) was notified of Resident#1's incident and no new orders were given.9/17/25 at 10:15 PM, the Administrator arrived at the facility and checked that all doors were functioning properly. The Administrator interviewed all employees and any residents that had interactions with Resident #1 prior to the incident.9/17/25 at 10:30 PM, Administrator began in-service for all employees on elopement policy and procedures. All staff would be in-serviced before returning to their next shift.9/17/25 at 10:46 PM, Administrator reported incident to State Agency.9/18/25 at 9:00 AM, an emergency Quality Assurance & Performance Improvement (QAPI) committee meeting was held to discuss incident, actions taken, and further interventions.9/18/25 at 9:15 AM, Social Services Director spoke with Resident #1 and noted no psychosocial harm due to incident.9/18/25 at 10:30 AM, Maintenance Director conducted a quality check of all doors to make sure they were operating as expected and door alarms were added to all of the doors. 9/18/25 at 11:00 AM, Regional Director of Operations interviewed Resident#1 and Resident #2 for any details they remember about the incident.9/18/25 at 12:25 PM, during education of elopement policy and procedures with dietary staff, Dietary Aide #1 stated that Resident #1 had followed him out of the building on 9/17/25. Dietary Aide #1 clocked out at 8:27 PM and went to the front door to exit. Dietary Aide #1 did not know the new front door code and went to nurse's station to get code. When Dietary Aide #1 came back through the facility, the resident followed him to the front door and went out behind him after 8:30 PM. Dietary Aide #1 stated that he sat in the parking lot until 8:50 PM with eyes on Resident #1 trying to determine if Resident #1 was a visitor.9/18/25 at 2:00 PM, wander assessments were completed on all active residents in the facility by DON, Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, and Medical Records LPN. One out of sixty-one residents was identified at risk for elopement.9/18/25 at 2:00 PM, Maintenance Director began elopement drills for all shifts and completed on 9/19/2025 at 5:30 AM.9/18/25 at 3:30 PM, a follow up QAPI committee meeting was held by Administrator to discuss that all interventions were in place. These interventions are as follows: Maintenance will conduct a quality check of all doors, an elopement drill on each shift within the next 24 hours and put alarms on each of the doors. Completed on 9/18/2025 at 2:00 PM: Administrative nurses completed wander assessments on all current residents, update care plans and wander books accordingly; completed a 100 percent audit of care plans; completed 100 percent audit of wander books located at both nurse's stations. Social services would interview Resident #1 for any psychosocial harm. Administrative staff would in-service all employees on elopement policy and procedures before their next shift. The root cause analysis determined by Administrator and DON found that the resident followed out a dietary employee while he was leaving at the end of his shift. It was determined through interviews with Dietary Aide #1 that he was unaware that Resident #1 was a resident, under the impression that she was a visitor. The QAPI committee meeting determined at this time to prevent further adverse events the interventions would include elopement drills on all shifts and one elopement drill per week for four weeks on alternating shifts and one per month for six months on alternating shifts. Person-centered in-services will be completed with all staff for any new residents identified as an elopement risk or any current residents who are newly identified as an elopement risk.9/22/25 at 4:40 PM, incident was reported to Attorney General's office by Administrator.Facility alleges that all corrective actions were complete on 9/18/2025 and Immediate Jeopardy removed on 9/19/2025.Validation:The SA validated through interview and record review view, that all corrective actions had been implemented as of 9/18/25, and the facility was in compliance as of 9/19/25, prior to the SA's entrance on 9/22/25.

Based on facility policy review, record review, and interviews the facility failed to notify Resident #1's primary physician following immediately of a change in status following an incident that required the resident to be transferred to the hospital for evaluation for one (1) of four (4) sampled residents. Resident #1. Resident #1 was left alone and unattended on the facility transport van for approximately 16 hours and 15 minutes which resulted in Resident #1 missing medications, meals, hydration, and care and assessments. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van after being abandoned on the facility's transport van after returning to the facility from a dialysis appointment on 9/15/23 at approximately 3:45 PM. The facility failed to notify the primary physician for Resident #1 immediately when staff located the resident and determined that she had been left unattended in the facility van for over sixteen (16) hours following her return to the facility after her hemodialysis treatment. Resident #1 was abandoned and restrained in her wheelchair by seat belts in the facility transport van and did not receive supervision or monitoring from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The facility's failure to notify the primary physician immediately placed this resident, and other residents, in a situation that was likely to cause serious harm, injury, impairment, or death. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The State Agency determined the situation to be an Immediate Jeopardy (IJ) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis. The resident received no treatment, supervision, monitoring or care during this time. The IJ existed at: 42 CFR 483.10(g)(14)(i)(B)(D) Notification of Changes; Scope and Severity J - F580 The State Agency (SA) notified the facility Administrator of the IJ on 9/26/23 at 1:15 PM and provided the IJ Template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23, prior to exit. Therefore, the scope and severity for F580; 42 CFR 483.10(g)(14)(i)(B)(D) Notification of Changes was lowered from a J to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Change in a Resident's Condition or Status .reviewed 08/2023 revealed that it was the facility's policy that the resident's attending physician be notified promptly of changes in the resident's status, specifically when there has been an incident involving the resident or need to transfer the resident to a hospital. Record review of the Facility Investigation revealed the Transportation Aide (TA) transported Resident #1 back to the facility following her dialysis treatment at an outside dialysis facility at about 3:30 PM on 9/15/23 and the resident remained strapped in her wheelchair in the facility van in the facility parking lot until about 7:45 AM on 9/16/23 without supervision, monitoring, or care and without the knowledge of facility staff. According to the Facility Investigation on 9/16/23 facility staff began to attempt to locate Resident #1 at 7:00 AM, the resident was located on the van at 7:45 AM. The resident was removed from the van at 7:50 AM and the staff provided a bed bath and breakfast, and the Director of Nurses (DON) was notified. The DON notified Resident #1's primary physician at or about 8:40 AM, fifty (50) minutes after the resident was located on the van, one (1) hour and forty (40) minutes after the staff began to attempt to locate the resident and approximately sixteen (16) hours after the resident was left alone, without supervision in the facility van. On 9/21/23 at 2:28 PM, an interview with CNA #2 revealed that she had worked on 9/15/23 and 9/16/23 and was assigned to the unit on the 7:00 AM to 7:00 PM (7A-7P shift). She assisted Registered Nurse (RN)#1 and other staff locating Resident #1 and removing her from the van. We observed Resident #1 seated in her wheelchair on the van, sweaty with throw-up and drool on her mouth and clothes and that her skin was hot, hot. Then we were instructed by RN #1 to bring her to her room, give her a bath, and assist with a meal. On 9/26/23 at 10:20 AM, an interview with the facility Medical Director/Primary Physician (MD) for Resident #1 stated that Resident's missed medications and care were a concern. He stated that as soon as he was notified, he issued an order for Resident #1 to be transferred via ambulance to the hospital emergency department (ED) for assessment and lab tests to protect the resident. He confirmed that there was a period of at least fifty minutes between the resident's removal from the van and his notification and that he would not characterize his notification as immediate or prompt. He stated that if he had been notified sooner, he would have, and did, order assessment and treatment as needed at the Emergency Department (ED). The DON stated during an interview on 9/26/23 at 1:35 PM, that RN #1 notified her by telephone at home on 9/16/23 at approximately 7:45 AM that nursing staff had located Resident #1 on the facility van after she arrived back at the facility from dialysis at approximately 3:30 PM the previous afternoon. The DON confirmed that she reported to the facility at or about 8:40 AM and assessed Resident #1 and notified the MD. The DON stated that she was aware that the regulations and the facility policy required the resident's primary physician to be notified immediately upon change of condition or status and said that postponement of fifty (50) minutes did not qualify as immediate or prompt. The DON described monitoring of the dialysis access site as very important for the safety of the resident. The DON stated that the results of the resident having sat up and strapped in her wheelchair in the van for over sixteen (16) hours could have resulted in negative results including serious negative cardiac results and that the resident could have lost a lot of blood due to lack of monitoring of the dialysis access site following dialysis treatment. The DON confirmed that the resident was supposed to receive care and monitoring in accordance with current standards of practice and the resident's care plan. Physician care instructions that were missed or omitted for the sixteen (16) hours the resident spent in the facility van unsupervised without the knowledge of the facility staff. Record review of the local hospital ED notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure .Rhabdomyolysis .Adult Neglect or Abandonment .Elevated Blood Pressure Reading. On 9/27/23 at 4:15 PM, an interview with the EDNP revealed that she considered Resident to #1 to be a risk for several potential negative cardiac results of having sat up in a wheelchair without care or repositioning for over sixteen (16) hours which included Rhabdomyolysis, Heat Exposure and Elevated Blood Pressure. Record review of the admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure with Stage 5 Chronic Kidney Disease, Dependence on Renal Dialysis, Diabetes, Hypertensive Urgency, Long Term (current) use of Insulin. The facility provided the following removal plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS (Minimum Data Set) Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review and interviews, the facility failed to ensure a resident was free from neglect for one (1) of four (4) sampled residents, Resident #1, as evidenced by on 9/15/23 at approximately 3:45 PM, after returning to the facility from a dialysis appointment the facility abandoned Resident #1 on the facility's transport van. Resident #1 was left alone and unattended on the facility transport van for approximately 16 hours and 15 minutes. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. This resulted in Resident #1 missing medications, meals, hydration, and care and assessments, and expressing that she was anxious, hurting, and afraid and, I thought I was doomed. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/15/23 when the facility abandoned Resident #1 on the facility transport van. The facility's neglect to provide ordered care and services placed Resident #1 and other residents who use the facility transport van for transfers in a situation that could likely lead to serious injury, impairment or death. The IJ and SQC existed at: 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation - F600, Scope and Severity J. The SA notified the facility's Administrator of the IJ and SQC on 9/26/23 and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.12-F600- Freedom from Abuse, Neglect and Exploitation was lowered from a Scope and Severity of J to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, update 10/2022, revealed, Policy Statement: Residents have the right to be free from abuse, neglect . Policy Interpretation and Implementation .1. Protect residents from .neglect by anyone including .a. facility staff . Record review of the admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive, Insulin-Dependent, Dependence on Renal Dialysis, chronic diastolic (congestive) heart failure, Type 2 Diabetes Mellitus, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic kidney disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 07 indicating Resident #1 had moderate cognitive impairment. Section G revealed for resident transfer, that the resident was an extensive assist with two people. Section H revealed the resident was always incontinent of bowel and bladder. Section J revealed Resident #1 experienced pain frequently. Section M revealed the resident was at risk for pressure ulcers/injuries. A record review of the facility-reported investigation, dated 9/19/2023, revealed, Incident: During shift report on 9/16/2023 at approximately 7:00 am (AM), the night shift informed the oncoming shift that the resident did not return from dialysis on 9/15/2023. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. On 9/20/23 at 9:30 AM, the State Agency (SA) observed Resident #1 sitting hunched over in the wheelchair with poor posture. The shunt/graft was covered by clothing. Resident was unable to stand. The SA observed a lift sling beneath the resident. The resident was soft-spoken and became short of breath during a conversation. During the interview, Resident #1 stated she was in bad shape. The Resident stated that she is always hungry, thirsty, and in pain. On 9/20/23 at 9:48 AM, an interview with Resident #1's daughter revealed her mother was left in her wheelchair overnight in the facility van because the Transportation Aide (TA) forgot to remove her. Resident #1's daughter also stated she was aware that her mother did not receive her nighttime medications, dinner, or any type of care for bedtime. During the interview, Resident #1's daughter confirmed the facility did not realize her mother was missing until the next day. Resident #1's daughter stated her mother always complains of being hungry, thirsty, and hurting. A record review of the Transportation Aide (TA)'s written statement revealed, on 9/16/23, .Arrived at (Proper Name of Facility) I noticed a elderly women falling so I jumped out of van to assist her the lady told me she was too weak then then pulled off. I went back inside (Proper Name of Facility) to finish up normal routine and left for the day. Around 7:15 AM I got a call asking about Resident #1 and I asked the nurse to check the bus .I would like to add that I arrived at (Proper Name of Facility) at or about 3:30 PM with Resident #1 . On 9/20/23 at 4:05 PM, an interview with the TA revealed on 9/15/23 at approximately 3:30 PM, she arrived from dialysis back to the facility with Resident #1 secured in the transport van. She parked and noticed a visitor who was in distress in the parking lot. She stated that she immediately jumped out of the parked van, closed the door, and assisted the visitor. Following the incident with the visitor, she stated that she clocked out and left the facility. The following day, 9/16/23, at approximately 7:20 AM, she received a phone call from the facility questioning where Resident #1 was. She realized that she had not removed Resident #1 from the van, and the resident remained unattended for approximately 16 hours. On 9/20/23 at 3:40 PM, an interview with Certified Nurse Assistant (CNA) #3 revealed that she worked on 9/15/23 until 7:00 PM. She was assigned to Resident #1. CNA #3 stated that Resident #1 usually returned to the facility around 4:30 PM. CNA #3 stated she informed Licensed Practical Nurse (LPN) #1, who was coming on 9/15/23 at 7:00 PM, that the resident wasn't back yet. A record review of the License Practical Nurse (LPN) #1's written statement revealed, . 9/15/23 I received report that patient had not returned from dialysis. After completed pm (PM) med (medication) pass resident had still not returned. At around 10 or so I tried to call (Professional Name Dialysis) with no answer. Reported told day nurse that she had not returned from dialysis . On 9/20/23 at 5:15 PM, an interview with LPN #1 revealed that she worked 9/15/23 from 7:00 PM until 9/16/23 at 7:00 AM. She said that at approximately 10:00 PM, she had one resident who had not received their medications, Resident #1. She stated, I realized (Resident #1) was the only resident that did not receive her hours' sleep medications. She stated, I called (the) dialysis unit and got no answer on 9/15/23 at 10:00 PM. LPN #1 revealed she received an admission on [DATE] at 10:00 PM and performed no further searches for Resident #1. The LPN confirmed on 9/16/23, she informed the day shift nurse and Registered Nurse (RN) #1 of the missing resident. LPN #1 confirmed that on 9/15/23 and 9/16/23 in the AM, Resident #1's shunt/ access site dressing was not observed for bleeding following dialysis. She also stated she did not give her medications, accucheck, or insulin. On 9/22/23 at 4:42 PM, an interview with the Administrator revealed that he was made aware on 9/16/23 at approximately 7:50 AM of the incident in which Resident #1 was last observed by facility staff strapped in her wheelchair on the facility van on 9/15/23 at approximately 3:30 PM and was located by facility staff strapped in her wheelchair on the facility van on 9/16/23 at approximately 7:45 AM. The Administrator confirmed that Resident #1 was left on the facility van following her dialysis treatment and did not receive any medications, food or fluids, care or services, or monitoring for sixteen (16) hours and fifteen (15) minutes. During an interview on 9/21/23 at 2:28 PM, an interview with CNA #2 revealed that she had worked on 9/15/23 and 9/16/23 and was assigned to the unit on the 7:00 AM to 7:00 PM (7A-7P shift). She assisted RN #1 and other staff finding Resident #1 and removing her from the van. We observed Resident #1 seated in her wheelchair on the van, sweaty with throw-up and drool on her mouth and clothes and that her skin was hot, hot. Then we were instructed by RN #1 to bring her to her room, give her a bath, and assist with a meal. During an interview on 9/26/23 at 10:20 AM, with the Medical Director (MD) revealed that there was potential for serious complications for Resident #1, , especially with her comorbidities. On 9/26/23 at 1:35 PM, an interview with the Director of Nursing (DON) revealed that on 9/15/23 at approximately 3:30 PM, the TA left Resident #1 in the facility van and was found on 9/16/23 at approximately 7:45 AM. The DON stated that the resident not receiving medications, supervision, or monitoring for over sixteen (16) hours could have resulted in serious injury or impairment. She stated that the failure of the facility to ensure the resident received the morning dose of insulin and monitoring of the blood glucose for Resident #1 on the morning of 9/16/23 could have resulted in the resident experiencing signs and symptoms of hyperglycemia. She said that failure to ensure the administration of respiratory medications on the evening of 9/15/23 for Resident #1 could have resulted in signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD), which could have hurt the resident's breathing or exacerbated the resident's disease process. The DON stated that the failure of the facility to provide the scheduled dose of blood pressure medication on the evening of 9/15/23 could have resulted in serious negative cardiac results. During the interview with the DON, she stated that the facility's failure to provide adequate and appropriate monitoring for Resident #1 from approximately 3:30 PM on 9/15/23 until 7:45 AM on 9/16/23 could have resulted in the serious injury or impairment of Resident #1. The DON confirmed that failure to monitor the resident dialysis graph/shunt site could have resulted in bleeding at the site, which could have resulted in the resident losing blood or hemorrhaging. She stated that monitoring the site following a dialysis appointment was very important for the resident's safety. The DON stated that failure to appropriately monitor Resident #1 for signs/symptoms of hyperglycemia (high blood glucose levels) for over sixteen (16) hours could cause negative results for Resident #1 and cause serious injury or impairment. The DON confirmed that the Resident did not receive supervision, appropriate monitoring, or any Activities of Daily Living (ADL) care during the sixteen (16) plus hours when she was not in the facility. A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed the following physician orders for blood pressure at 7-10 P: Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed the following physician orders to monitor access site Right Upper Arm for thrill & bruit, two times a day and observe dressing to right arm two times a day. A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed her diabetic medication and accucheck on 9/16/23 of Insulin Detemir Solution 100 UNIT/ML (milliliter) and accucheck is less than 60 mg/dl (deciliter) or greater than 400 mg/dl. A record review of the Order Summary Report as of 9/25/23 revealed an order for Proventil HFA (bronchitis). Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/15/23, the following medications were coded as 3 (resident absent from home) and not administered for blood pressure Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/16/23, the following medications were coded as 3 (resident absent from home) and not administered: Insulin Detemir Solution, Accu check, and Proventil for bronchitis. In a record review Documentation Survey revealed, the facility failed to perform ADL (Activities of Daily Living) on Resident #1 for 16 hours and 15 minutes, on 9/15/23 through 9/16/23. Record review revealed Resident #1 had no progress reports from 9/7/23 till 9/16/23 at 9:40 AM. Record review of Resident #1's Progress Notes revealed, 9/16/23 09:40 (9:40 AM) Note Text, Arrived to facility at approx. (approximately) 8:40 AM in regards to resident being left on facility transport van overnight . MD (Medical Doctor) notified of incident and findings .Orders received to send to ER (Emergency Room). At approx. (approximately) 0920 (9:20 AM) Report was called to (Formal Name/local hospital) ER, Admin (Administrator) aware of incident and also at facility at this time. RP (Responsible Party) arrived to facility at approx. 0930 (9:30 AM) and Admin informed RP of incident and status of resident. Resident left facility at via stretcher at this time. The Emergency Department Nurse Practitioner (EDNP) from the local hospital confirmed in an interview on 9/27/23 at 4:15 PM, that she assessed and treated Resident #1 at the local hospital ED on 9/16/23 and that she had diagnosed Resident #1 with Heat Exposure, Neglect, and Abandonment. The EDNP confirmed her blood pressure was elevated and considered hospitalization. However, while blood tests revealed Creatine Phosphokinase (CPK) levels elevated to approximately ten (10) times the normal levels, this finding did not reach the threshold for hospitalization. The EDNP explained that Resident #1's elevated CPK levels were indicative of the resident being in one position for an extended period of time which led to the breakdown of muscle tissue due to muscle damage. The EDNP stated that while Resident #1 did not have devastating results, her health was compromised. The EDNP stated that Resident #1 was in an extremely dangerous situation and noted conditions that contributed to this situation included having missed routinely scheduled doses of hypertension medications, food, and fluids for twenty-four (24) hours and exposure to hot, humid conditions for over sixteen (16) hours. The EDNP stated that Resident #1 had not received any psychosocial assessment during her time at the emergency department (ED). She stated that the ED's dedicated Case Worker was not on duty on 9/16/23 and that the Case Worker on duty had communicated with the facility related to giving a report to the staff and communication with the family of Resident #1 to confirm their approval to return Resident #1 to the facility. She stated that psychosocial assessments were normally under the canopy of a certified psychiatric provider. She stated that she had not completed a thorough psychosocial assessment. She said that she had only documented observations on the ED Progress/Discharge notes. Record review of the hospital emergency department (ED) report signed by Acute Care-NP; Emergency Medicine (EDNP) revealed that on 9/16/23. The PHYSICIAN ATTESTATION NOTE signed by the EDNP stated that Resident #1 was assessed and received treatment at the ED after being left in the transport vehicle overnight. Record review of the local hospital Emergency Department (ED) notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure .Rhabdomyolysis .Adult Neglect or Abandonment .Elevated Blood Pressure Reading. Record review of the Progress Note dated 9/27/23, revealed Resident #1 was seen for counseling by a contracted Licensed Certified Social Worker (LCSW) on 9/27/23 with Chief complaint listed as A recent Incident. Resident was left overnight in the facility transport LCSW asked to assess resident 2* (secondary) to this event. The progress note review revealed Resident Quote; I thought I was doomed .Resident reports current emotional status or behavior as: Tired and concerned that the incident (being left in the transport van overnight) not be repeated and another resident suffer as she had. Today resident discussed: The Incident of being left in the transport van. Resident shared that she was anxious, hurting, and afraid. She explained that she got through the night by crying and being worried and didn't sleep at all. When asked if it was the most frightened, she had ever been in her life, resident stated it was not but close .she feels she was denied the help I was supposed to get and added she is resentful and angry about the incident . On 9/28/23 at 11:10 AM, a telephone interview with the facility's contracted Licensed Certified Social Worker (LCSW) revealed that regarding the cognitive level of Resident #1, the resident was able to express her feelings and needs verbally. She was sure Resident #1 remembered being in the facility van overnight on 9/15/23 because Resident #1 was able to describe being in the wheelchair and the van, and the pain and fear she felt. The LCSW stated that the incident was definitely detrimental in the way she was frightened and talked about not being provided with care. The LCSW reported that Resident #1 stated, I was denied the care I needed during their conversation on 9/27/23. The LCSW reported that effects from the incident may appear over time and said, That will be found out in days to come. The facility provided the following removal plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with Resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect.[TRUNCATED]

Based on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions to ensure Resident #1 received care and services for monitoring after hemodialysis, significant medications, accu check and activities of daily living, for one (1) of four (4) resident care plans. Resident #1. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van. The facility failed to implement the plan of care for Resident #1 when Resident #1 was left unattended, unsupervised without care or monitoring following transportation from hemodialysis treatment. Resident #1 was abandoned and restrained by seat belts in a wheelchair in the facility transport van. The staff was unaware of Resident #1's absence from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23 for over sixteen (16) hours without care as listed on the care plan, placed this resident, and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/15/23, when the facility abandoned Resident #1 on the facility van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis. The resident received no treatment, supervision, monitoring or care as designated per the care plan during this time. The IJ existed at: 42 CFR 483.21(b)(1) Comprehensive Care Plans - F656 - Scope and Severity J; The State Agency (SA) notified the facility Administrator of the IJ on 9/26/23 at 1:15 PM and provided the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.21(b)(1) Comprehensive Care Plans - F656 - Scope and Severity J; was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy Using the Care Plan with a revision date of 9/25/23, revealed, Policy statement: It is the policy of this facility that the care plan be used in developing the resident's daily care routines Record review of the Care Plans, undated, for Resident #1 revealed the following care plans were not implemented: Activities of Daily Living: Focus: I have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) .Dementia .Interventions/Task, Eating, Toilet Use, Transfer . Hypertension: Focus: I have hypertension .Interventions/Task .Give anti-hypertensive medications as ordered. Monitor for side effects . Impaired cognitive function: Focus: I have impaired cognitive function/dementia .Interventions/Task .Administer medications as ordered. Observe/document for side effects and effectiveness .Keep my routine consistent . Diabetes: Focus: I have Diabetes Mellitus .Interventions/ Task .Diabetes medication as ordered by doctor. Monitor for side effects and effectiveness . Pain: Focus: I have acute/chronic pain .Interventions/Task .Administer analgesia as per orders .Evaluate effectiveness of pain interventions . Hemodialysis: Focus: I am on hemodialysis r/t renal failure .Interventions/Task .Check dressing daily at access site, monitor vital signs q (every) shift Skin integrity: Focus: I have potential for impairment to my skin integrity .Interventions/Task .Keep body parts from excessive moisture .Encourage .good nutrition and hydration . Chronic Obstructive Pulmonary Disease (COPD) Focus: I have COPD .Interventions/Task Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness .Monitor for s/sx (signs or symptoms) of .Anxiety, Confusion, Restlessness, SOB (Shortness of Breath) at rest . A record review of the facility-reported investigation, dated 9/19/2023, revealed, Incident: During shift report on 9/16/2023 at approximately 7:00 am (AM), the night shift informed the oncoming shift that the resident did not return from dialysis on 9/15/2023. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. Record review of the Documentation Survey Report .Tasks Only for Resident #1 for 9/15/23 and 9/16/23 revealed that there was no documentation of the resident receiving assistance in accordance with the Minimum Data Set (MDS) assessment or the resident's care plan or physician orders for Bed Mobility, Hygiene, or Toilet Use on 9/15/23 through 6:59 PM on 9/16/23. There was no documentation for Eating and Drinking or percent of meals or nourishments/snacks eaten or fluid intake for 9/15/23 through 8:00 AM on 9/16/23. There was no documentation for Bladder continence or Bowel Movements and no observations of skin or behaviors recorded on 9/15/23 through 6:59 PM on 9/16/23. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/15/23, the following medications were coded as 3 (three) (absent from home) and not administered for blood pressure Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/16/23, the following medications were coded as 3 (absent from home) and not administered: Insulin Detemir Solution, Accu check, and Proventil for bronchitis. On 9/20/23 at 3:10 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed that she worked as the medication nurse on 9/15/23 7 PM-7 AM shift and confirmed she did not follow the care plan of giving Resident #1 her medications or checking her accu check. During the interview, she stated if the resident was available, she should have followed the care plan to provide her with medication because it is the process for staff to take care of the residents. On 9/20/23 at 3:20 PM, an interview with Certified Nursing Assistant (CNA) #3 confirmed that Resident #1 had not received any supervision, monitoring, care, food or fluids after the resident left for dialysis on 9/15/23 at approximately 10:00 AM through 7:00 PM when the CNA completed her shift. On 9/26/23 at 1:35 PM, an interview with the Director of Nurses (DON) revealed it is my expectation that the nursing staff follow the care plans of all residents. The care plans provide a detailed and effective personalized outline of care for our residents. On 9/26/23 at 10:20 AM an interview with the Medical Director who is the primary physician confirmed that Resident #1 could have potentially suffered serious complications with her comorbidities; potentially serious injury or impairment, including but not limited to signs/symptoms (s/s) hyperglycemia or hypoglycemia, s/s of Chronic Obstructive Pulmonary Disease, negative effects of hypertension due to lack of monitoring while on the facility van for over sixteen (16) hours. The MD confirmed that he expected the facility nursing staff to follow the residents' care plans to ensure appropriate care for each resident. On 9/26/23 at 3:00 PM, an interview with LPN #2 reported that care plans were developed for individualized care and to ensure consistency in the nursing care of the resident, which helps improve services. LPN #2 added that she expects all nursing staff in the facility to follow care plans for the residents. Record review of the admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive, Insulin-Dependent, Dependence on Renal Dialysis, Chronic Diastolic (congestive) Heart Failure, Type 2 Diabetes Mellitus, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 07 indicating Resident #1 had severe cognitive impairment. Section G revealed for resident transfer, that the resident was an extensive assist with two people. Section H revealed the resident was always incontinent of bowel and bladder. Section J revealed Resident #1 experienced pain frequently. Section M revealed the resident was at risk for pressure ulcers/injuries. The facility provided the following removal plan on 9/28/23. On 9/26/2023 1:15 PM the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on record review and interviews the facility failed to provide resident centered care and services in accordance with the resident's individualized care plan and professional standards of practice that met Resident #1's physical, mental, and psychosocial needs for one (1) of four (4) sampled residents, Resident #1, as evidenced by the facility abandoned Resident #1 on the facility's transport van after returning to the facility from a dialysis appointment on 9/15/23 at approximately 3:45 PM. Resident #1 was left alone and unattended on the transport van for approximately 16 hours and 15 minutes which resulted in Resident #1 missing medications, meals, hydration, care and assessments. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van and transferred the resident to their room in the facility. Registered Nurse (RN) #1 completed an assessment revealing the resident's temperature 100.3 Fahrenheit, blood pressure 175/79, pulse 97, and Oxygen Saturation 100%. The facility did not obtain a blood glucose level at the time of assessment. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/15/23 when the facility abandoned Resident #1 on the facility transport van. The facility's failure to provide care and services in accordance with professional standards to maintain a resident's highest practicable well-being placed Resident #1 and other residents who use the facility transport van in a situation with the likelihood of serious injury, harm, impairment or death. The IJ and SQC existed at: 42 CFR 483.25, Quality of Care - F684 Scope and Severity J The SA notified the facility's Administrator of the IJ and SQC on 9/26/23 at 1:15 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.25, Quality of Care was lowered from a J to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility did not provide a specific policy on Quality of Care. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/15/23, the facility coded the following medications and services as '3' (resident absent from home) and failed to administer: Lyrica, Pravastatin Sodium, Risperdal, Amlodipine Besylate, Hydrocortisone Acetate, Lidocaine-Prilocaine, Memantine HCL, Metoprolol Tartrate, Clonidine HCL, Hydralazine HCL, Nephro-Vite, Proventil HFA, and Calazime, monitoring of access site, application of Nystatin external powder, observation of dressing right arm, vital signs, rate level of pain, monitor behaviors exhibited, or check fluids, . Boost was coded 1 away from home with meds. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/16/23, the facility coded the following as 3 (resident absent from home) and failed to administer: Insulin Detemir Solution, Protonix, Synthroid, Boost, Clonidine, Hydralazine, Nephro-Vite, and Proventil. Record review of the Documentation Survey Report .Tasks Only for Resident #1 for 9/15/23 and 9/16/23 revealed that there was no documentation of the resident receiving assistance in accordance with the Minimum Data Set (MDS) assessment or the resident's care plan or physician orders for Bed Mobility, Hygiene, or Toilet Use from 9/15/23 through 9/16/23 at 6:59 PM. There was no documentation for Eating and Drinking or percent of meals or nourishments/snacks eaten or fluid intake from 9/15/23 through 8:00 AM on 9/16/23. There was no documentation for Bladder continence or Bowel Movements and no observations of skin or behaviors recorded on 9/15/23 through 6:59 PM on 9/16/23. Record review of the local hospital Emergency Department (ED) notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure .Rhabdomyolysis .Adult Neglect or Abandonment .Elevated Blood Pressure Reading. On 9/20/23 at 3:10 PM, an interview with RN #2 revealed that she worked as the medication nurse for Transitional Care Unit (TCU) at the facility from 8:00 AM through 4:30 PM on 9/15/23. She said that Resident #1 was propelled to the facility van for transportation to a dialysis appointment on 9/15/23 between 9:45 (AM) and 10:00 (AM) as usual. RN #2 confirmed that she did not observe Resident #1 for the rest of the day. RN #2 stated that the facility did not send food, fluids or medications for residents to dialysis appointments. An interview with Certified Nursing Assistant (CNA) #3 on 9/20/23 at 3:20 PM, revealed she worked 7:00 AM through 7:00 PM on 9/15/23 on the TCU and that she had mentioned to Licensed Practical Nurse (LPN) #1 that Resident #1 was not in her room at approximately 7:00 PM, when the CNA had clocked out for the day and left the building. CNA #3 confirmed that Resident #1 had not received any supervision, monitoring, care, food or fluids after the resident left for dialysis at approximately 10:00 AM through 7:00 PM when the CNA left work on 9/15/23. In an interview with LPN #1 on 9/20/23 at 5:15 PM, she confirmed that she was assigned to provide care for Resident #1 for the 7:00 PM to 7:00 AM shift on 9/15/23. She reported that she had arrived and clocked in at approximately 6:30 on 9/15/23 and relieved LPN #3 on the TCU and during shift change report, was told by LPN #3 that Resident #1 had not returned from her dialysis appointment. LPN #1 stated that Resident #1 had not received any supervision, monitoring, care, food, fluids, pain management or medications from 6:30 PM on 9/15/23 through 9/16/23 at 7:00 AM when the LPN had clocked and left the facility. In an interview on 9/21/23 at 2:28 PM, CNA #2 confirmed that AM (morning) care for each resident should include monitoring for and provision of incontinence/toileting needs, hygiene (which she said would include oral care/toothbrushing, washing hands and face, and use of personal care products of preference, such as deodorant/antiperspirant) and getting ready. CNA stated, Normally when she (Resident #1) gets back from dialysis, we heat her lunch up and she eats it and then she lays down cause she's tired from dialysis. Normally the Transportation Aide drops the resident off at the common area at the nurse's station and that's where she (Resident #1) eats her lunch. CNA #2 stated that Resident #1's CNA would then assist Resident #1 with transfer into bed and provide care as needed including monitoring for and provision of incontinence/toileting needs and hygiene. She stated that Resident #1 normally ate her evening meal (supper) in bed. CNA #2 confirmed that Resident #1 did not receive any care, monitoring (including monitoring of skin or behaviors), supervision, food, or fluids from 7:00 PM on 9/15/23 to 7:00 AM on 9/16/23, because she was on the van. CNA #2 stated that on 9/16/23 she and CNA #3 arrived on TCU unit at approximately 7:00 AM and asked the 7 PM-7 AM shift nurse and they told us that (Resident #1) had not come back from dialysis. She reported that they went down hall to do rounds and then, during breakfast, she (Resident #1) was found on the van on 9/16/23 at approximately 7:45 AM. She stated that she had gone to the van and observed Resident #1 seated in her wheelchair on the van, sweaty with throw-up and drool on her mouth and clothes and that her skin was hot, hot. CNA #2 stated that Resident #1 required assistance with a bed bath, hygiene, eating, dressing and had her vital signs measured by staff upon return to her room at approximately 7:50 AM on 9/16/23. On 9/21/23 at 3:00 PM, an interview with the facility Medical Director (MD), who was the Resident #1's primary physician, confirmed he had been made aware of the incident by the Administrator and DON on the morning of 9/16/23 at or about 8:40 AM and was told that the Transportation Aide forgot to transfer Resident #1 from the van to the facility on the evening of 9/15/23 upon return from a dialysis appointment and Resident #1 had spent the night in the van and was found on the van at approximately 7:45 AM on 9/16/23. The MD confirmed that the resident would have required monitoring for signs and symptoms of dehydration and monitoring of the dialysis shunt site for bleeding, which the facility failed to provide for over sixteen (16) hours due to Resident #1 being in the van without awareness of the staff. The MD confirmed that the resident did not receive any care supervision, monitoring, food, physician ordered medications or hydration from approximately 3:30 PM on 9/15/23 through approximately 7:50 AM on 9/16/23. The Administrator revealed on 9/22/23 at 4:42 PM, during an interview that he was made aware on 9/16/23 at approximately 7:50 AM of the incident in which Resident #1 was left alone on the facility van following her dialysis treatment. The Administrator confirmed she was last observed by facility staff strapped in her wheelchair on the facility van on 9/15/23 at approximately 3:30 PM and was located by facility staff still strapped in her wheelchair on the facility van on 9/16/23 at approximately 7:45 AM. He confirmed that Resident #1 did not receive any medications, food or fluids, care or services or monitoring for approximately sixteen (16) hours and fifteen (15) minutes. On 9/26/23 at 10:20 AM, an additional interview with the Medical Director confirmed that Resident #1 could have potentially suffered serious complications with her comorbidities; potentially serious injury or impairment, including but not limited to signs/symptoms (s/s) hyperglycemia or hypoglycemia, s/s of Chronic Obstructive Pulmonary Disease, negative effects of hypertension due to lack of monitoring while on the facility van for over sixteen (16) hours. Record review of the admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive Urgency, Long Term (current) use of Insulin, End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Diastolic (congestive) Heart Failure, Type 2 Diabetes Mellitus, long-term current use of insulin, Dependence on renal dialysis, End stage renal disease, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score is 07 indicating Resident #1 had severe cognitive impairment. Section G revealed for resident transfer, that the resident was extensive assist with two people. Section H revealed the resident was always incontinent of bowel and bladder. Section J revealed the resident had pain frequently. Section M revealed that the resident was at risk for pressure ulcers/injuries. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on policy review, record review, and interviews, the facility failed to provide supervision for a resident who was left alone, abandoned, strapped in her wheelchair without monitoring on the facility transport van following a dialysis treatment for approximately 16 hours and 15 minutes for one (1) of four (4) Residents reviewed. Resident #1. The facility failed to remove the resident from the facility van following transportation from her hemodialysis treatment, abandoning the resident restrained by seat belts in a wheelchair in the facility transport van, without supervision or monitoring. The staff was unaware of Resident #1's location from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van. The facility's failure to supervise Resident #1 placed this resident, and other resident, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/15/23, when the facility abandoned Resident #1 on the facility van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis. The resident received no treatment, supervision, monitoring or care during this time. The IJ and SQC existed at: CFR 483.25(d)(2) Accidents - F689 Scope and Severity J The State Agency (SA) notified the facility Administrator of the IJ and SQC on 9/26/23 at 1:15 PM. The facility provided an acceptable Removal Plan on 9/27/23, in which the facility alleged all corrective actions were completed on 9/27/23 to remove the IJ on 9/28/23. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23, prior to exit. Therefore, the scope and severity for F689 - 483.25(d)(2) Accidents scope and severity J was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Accidents and Incidents with a revision date of 9/25/23, revealed, Policy: It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible, and those residents receive supervision and assistance devices to prevent accidents whenever possible . A record review of the Facility Investigation, dated 9/19/2023, revealed, during shift report on 9/16/2023 at approximately 7:00 am (AM), the night shift informed the oncoming shift that the resident did not return from dialysis on 9/15/2023. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. A record review of Resident #1's Incident Report revealed, 9/16/23 13:38 (1:38 PM), .writer notified of resident being left in facility transport van after dialysis yesterday evening. Resident was located in facility van the AM . A record review of the Transportation Aide (TA's) written statement revealed, on 9/16/23, .Arrived at (Proper Name/facility) I noticed a elderly women falling so I jumped out of van to assist her the lady told me she was to weak then pulled off. I went back inside (Proper Name of facility) to finish up normal routine and left for the day. Around 7:15 AM I got a call asking about Resident #1 and I asked the nurse to check the bus .I would like to add that I arrived at (Proper Name of facility) at or about 3:30 PM with Resident #1 . An interview with the TA on 9/20/23 at 4:05 PM, revealed that 9/15/23, After receiving Resident #1 from dialysis, I drove back to the facility and parked the van, with Resident #1 secured in the van. The TA noticed a visitor who was in distress in the parking lot and assisted the visitor. Following the incident with the visitor, she clocked out and left the facility. The following morning, she received a phone call from the facility questioning where Resident #1 was located. At that moment, she realized she had not transferred the resident from the van to the facility. The resident remained unattended for approximately 16 hours while in the facility van. A record review of Licensed Practical Nurse (LPN) #1's written statement revealed, . On 9/15/23, I received a report that patient had not returned from dialysis. After completed pm (PM) med (medication) pass resident had still not returned. At around 10 or so I tried to call (Professional Name/Dialysis) with no answer. Reported to the oncoming nurse that she had not returned from dialysis . On 9/20/23 at 5:15 PM, an interview with LPN #1 confirmed she was assigned to Resident #1 on 9/15/23 at 7:00 PM until 9/16/23 at 7:00 AM. LPN #1 stated that on 9/15/23 at 10:00 PM, Resident #1 did not receive her medications and was not in the building. She assumed she was at the hospital or still at dialysis. She attempted to contact dialysis unsuccessfully and passed on to the oncoming nurse on 9/16/23 at 7:00 AM that Resident #1 was not in the building. On 9/20/23 at 10:25 AM, an interview with the Director of Nurses (DON) confirmed that Resident #1 was left in the facility transport van, strapped in her wheelchair from 9/15/23 at approximately 3:30 PM until 9/16/23 at 7:45 AM, when she was located by the facility staff. The DON revealed the resident was unattended for approximately 16 hours and 15 minutes. During an interview on 9/20/23 at 3:40 PM, Certified Nurse Assistant (CNA) #3 revealed that she worked the day shift at the facility on Friday, 9/15/23, until 7:00 PM and confirmed Resident #1 was not in the facility. She reported to the night shift nurse (LPN #1) that Resident #1 was not in the facility. When she arrived at work on 9/16/23 at approximately 7:45 AM, Resident #1 was in the facility van strapped in her wheelchair. A record review Registered Nurse (RN) #1's written statement revealed, .At approximately 7:10, I was notified by night shift nurse and oncoming nurse and Certified Nurse Assistant (CNA) that resident did not return to facility from Dialysis on 9/15/23. Night shift nurse stated, I do not know where she is, I did not realize she was still gone around 10 pm (PM). Called TA, she stated, Oh my gosh, check the van. Resident was seen in the van, shoulders moving up and down indicating she was breathing. On 9/21/23 at 9:23 AM, an interview with Registered Nurse (RN) #1 confirmed on 9/16/23 that she was informed that Resident #1 was not in the building. She stated she started making phone calls to locate the resident. The TA advised her to look in the facility van, where she was located still strapped in her wheelchair. Resident #1 was strapped in her wheelchair and the facility van for approximately 16 hours and 15 minutes with no supervision. In an interview on 9/22/23 at 4:42 PM, with the Administrator, confirmed Resident #1 was last observed on the facility van when she was transported from dialysis on 9/15/23 at approximately 3:30 PM. The Administrator conveyed that he was informed on 9/16/23 at approximately 7:50 AM of the incident that Resident #1 was left unattended on the facility van following her dialysis treatment for approximately 16 hours and 15 minutes, with no supervision. In an interview on 9/26/23 at 10:20 AM, with the Medical Director (MD) revealed the potential for serious complications for Resident #1 for being unsupervised and left in the facility van for over 16 hours. In an interview on 9/26/23 at 1:35 PM, with the DON revealed that on 9/15/23 at approximately 3:30 PM, the TA left Resident #1 in the facility van and was found on 9/16/23 at approximately 7:45 AM. The DON stated that the resident not receiving medications, supervision, or monitoring for over sixteen (16) hours could have resulted in serious injury or impairment. The DON confirmed that the Resident did not receive supervision, appropriate monitoring or any Activities of Daily Living (ADL) care, during the sixteen (16) plus hours when she was not in the facility. On 9/27/23 at 3:13 PM, an interview with RN #4 from the dialysis clinic confirmed Resident #1's dialysis was completed, and she was transported from the dialysis clinic to the facility on 9/15/23 at approximately 3:15 PM, by a facility staff member. She was unsure of who performed the transport. Record review of the local weather temperature for 9/15/23 at approximately 3:45 pm through 9/16/23 at 8:40 AM, when the facility located Resident #1, ranged from 89 degrees Fahrenheit to 77 degrees Fahrenheit and was obtained at https://www.timeanddate.com. Record review of the admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertension, Insulin-Dependent, Dependence on Renal Dialysis, Chronic Diastolic (congestive) Heart Failure, Type 2 Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic kidney disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 07 indicating Resident #1 had severe cognitive impairment. Section G revealed for resident transfer that the resident was an extensive assist with two people. Section H revealed the resident was always incontinent of bowel and bladder. Section J revealed Resident #1 experienced pain frequently. Section M revealed that the resident was at risk for pressure ulcers/injuries. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3 Fahrenheit, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with Resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on interview, record review, and facility policy review, the facility failed to ensure Resident #1 received care and services following a hemodialysis treatment consistent with professional standards of practice including ongoing assessment of the resident's condition and monitoring for complications after dialysis treatments for one (1) of four (4) residents reviewed, Resident #1 as evidenced by the facility failed to remove the resident from the facility van on 9/15/23 following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair restrained by the seatbelts in the facility van for sixteen (16) hours and fifteen (15) minutes without the staff's monitoring. The facility's failure to provide treatment, monitoring, care, food, or fluids after hemodialysis placed this resident and other residents in a situation that has caused and is likely to cause serious harm, injury, impairment, or death. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/15/23, when the facility abandoned Resident #1 on the facility van. The IJ and SQC existed at: 42 CFR 483.25(l) Dialysis - F698 Scope and Severity J. The SA notified the facility's Administrator of the IJ and SQC on 9/26/23 and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.25(l) Dialysis - F698 was lowered from a J to D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy, Clinical Practice Guideline Dialysis-Hemodialysis dated March 24, 2010, revealed the Objectives .To ensure the resident is assessed and/or observed appropriately .to ensure adequate nutrition and hydration .The access device should be observed for complications at least every shift and more frequently if the resident has just been dialyzed. These observations should include the appearance of the device, and the presence or absence of sign/symptoms of infection, and the presence of bruit or thrill if applicable. Observations of the resident's mental status, dialysis access, respiratory status, body/skin condition, pain status, and urine output should be done pre and post dialysis .Ongoing observations/assessments of the resident's skin should be done. Ongoing observations/assessments of the resident's fluid balance, nutritional state, mental status, respiratory status, and cardiovascular status should be done. In an interview on 9/20/23 at 4:05 PM, the Transportation Aide (TA) revealed that on 9/15/23 she had transported Resident #1 from the dialysis facility following the resident's dialysis treatment to the facility at approximately 3:45 PM. She said she encountered a situation in the parking lot upon return to the facility, prior to unloading Resident #1, in which she had gone to the assistance of a visitor. She stated that she went inside the facility and forgot to unload Resident #1. The TA stated that after checking to see if she had any more transports for the day (and discovering that she did not) she clocked out and left the facility and left Resident #1 secured in her wheelchair in the van. She said she did not think any more about Resident #1 until she received a telephone call the following morning from Registered Nurse (RN) #2 who asked her if she had picked Resident #1 up from the dialysis facility. The TA stated she immediately told RN #2 to go check the van. Certified Nurse's Aide (CNA) #3 revealed on 9/20/23 at 3:20 PM, in an interview that she had worked 7:00 AM through 7:00 PM on 9/15/23 on TCU and that she had mentioned to Licensed Practical Nurse (LPN) #1 that Resident #1 was not in her room at approximately 7:00 PM, when the CNA clocked out for the day and left the building. CNA #3 confirmed that Resident #1 had not received any observation, monitoring, care, food, or fluids after the resident left for dialysis at approximately 10:00 AM through 7:00 PM when the CNA left work on 9/216/23. In an interview on 9/20/23 at 5:15 PM, Licensed Practical Nurse (LPN) #1 confirmed she was assigned to provide care for Resident #1 from 7:00 PM on 9/15/21 to 7:00 AM on 9/16/23. She reported that she had arrived and clocked in at approximately 6:30 PM on 9/15/23 and relieved LPN #3 on the Transitional Care Unit (TCU) and during shift change report was told by LPN #3 that Resident #1 had not returned from her dialysis appointment. LPN #1 stated that at approximately 10:00 PM on 9/15/23 she noted that the only resident she had not completed medication administration for was Resident #1 and she had attempted to contact the dialysis facility by telephone without success but did not attempt to contact anyone else. LPN #1 stated that Resident #1 had not received any observation, monitoring, care, food, or fluids from 6:30 PM on 9/15/23 through 9/16/23 at 7:00 AM when the LPN had left the facility with no knowledge of the location of the resident. CNA #2 revealed on 9/21/23 at 2:28 PM, during an interview that Resident #1 did not receive any care, monitoring, observation, or fluids from 7:00 PM on 9/15/23 to 7:00 AM on 9/15/23, because she was on the van. CNA #2 stated that on 9/16/23 she and CNA #3 arrived on the TCU at approximately 7:00 AM and asked the 7PM-7AM shift nurse and they told us that (Resident #1) had not come back from dialysis. She reported that they went down hall to do rounds and then, during breakfast, she (Resident #1) was found on the van at approximately 7:45 AM. She stated that she had gone to the van and observed Resident #1 secured in her wheelchair on the van, sweaty with throw-up and drool on her mouth and clothes and that her skin was hot, hot. On 9/21/23 at 3:00 PM, during an interview with the facility Medical Director (MD), who was Resident #1's primary physician, he confirmed that the resident would have required monitoring for signs and symptoms of dehydration and monitoring of the dialysis shunt site for bleeding, which the facility failed to provide for over sixteen (16) hours due to Resident #1 being in the van without awareness of the staff. The Administrator revealed on 9/22/23 at 4:42 PM, during an interview that he was made aware on 9/16/23 at approximately 7:50 AM of the incident in which Resident #1 was left alone on the facility van following her dialysis treatment. The Administrator confirmed she was last observed by facility staff strapped in her wheelchair on the facility van on 9/15/23 at approximately 3:30 PM and was located by facility staff still strapped in her wheelchair on the facility van on 9/16/23 at approximately 7:45 AM. He confirmed that Resident #1 did not receive any medications, food or fluids, care or services or monitoring for approximately sixteen (16) hours and fifteen (15) minutes. On 9/26/23 at 10:20 AM, in a later interview with the MD, he confirmed that Resident #1 could have potentially suffered serious complications with her comorbidities including potentially serious injury or impairment due to lack of monitoring and care while on the facility van for over sixteen (16) hours. The MD stated that there were additional risks related to no fluids provided to the resident for over 16 hours following hemodialysis. He stated that following dialysis monitoring of the resident's vital signs and monitoring for bleeding at the access site would have been important. Record review of the local hospital Emergency Department (ED) notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure .Rhabdomyolysis .Adult Neglect or Abandonment .Elevated Blood Pressure Reading. The ED notes included consideration of intravenous fluids avoided due to the residents diagnosis of End Stage Renal Disease. On 9/27/23 at 4:15 PM, an interview with the EDNP revealed that she considered Resident to #1 to be a risk for several potential negative cardiac results of having sat up in a wheelchair without care or repositioning for over sixteen (16) hours which included Rhabdomyolysis, Heat Exposure and Elevated Blood Pressure. Record review of Resident #1's 9/2023 Medication Administration Record (MAR) revealed on 9/15/23 the following were coded as '3' for (resident absent from home) and not administered: prescribed fluids to be provided related to dialysis, monitoring dialysis access site, observation of dressing right arm, and vital signs. Record review of the interdisciplinary progress notes for Resident #1 for September 2023 revealed there were no entries that documented the resident leaving or returning to the facility for or following dialysis appointments/treatments. Record review of the Dialysis Transfer Forms for Resident #1 for September 2023 revealed that out of ten (10) forms, four (4) of the forms were completed in the section labeled Upon Return to Facility Following Dialysis; the section was not completed for the Dialysis Transfer Form dated 9/15/23. Record review of the Sign Out binder at the TCU nurses' station and the [NAME] Hall nurses stations for September 2023 revealed that there were no entries that documented any of the sampled residents, who relied on the facility for transportation for dialysis treatments at a dialysis unit outside of the facility, having been signed out or back in from dialysis appointments prior to 9/16/23. Record review of the Documentation Survey Report .Tasks Only for Resident #1 for 9/15/23 and 9/16/23 revealed that there was no documentation of the resident receiving assistance in accordance with the MDS assessment or the resident's care plan or physician orders for 'Eating and Drinking' or percent of meals or nourishments/snacks eaten or fluid intake for 9/15/23 through 8:00 AM on 9/16/23. There was no documentation for observations by Certified Nurse's Aides (CNAs) on 9/15/23 through 6:59 PM on 9/16/23. Record review of the admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 5 Chronic Kidney Disease or End Stage Renal Disease, Dependence on Renal Dialysis, Diabetes, Hypertensive Urgency, and Long Term (current) use of Insulin. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score is 07, which indicated severe cognitive impairment and Section O indicated that the resident received renal dialysis. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and immediacy removed it on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on interview, record review, and facility policy review, the facility failed to provide adequate staffing to ensure the safety and the necessary care and services for one (1) of four (4) residents reviewed, Resident #1. The facility failed to identify the location of a resident when the resident failed to return to the facility unit following transportation from her hemodialysis treatment. This resulted in the facility abandoning the resident restrained by seat belts in a wheelchair in the facility transport van, without supervision or monitoring. The staff was unaware of Resident #1's absence from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The facility's failure to staff the facility sufficiently resulted in Resident #1 been left unattended in the facility van for over sixteen (16) hours. This placed Resident #1 in a situation that was likely to cause serious harm, injury, impairment, or death. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/15/23, when the facility failed to locate Resident #1 on the facility van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis. The resident received no treatment, supervision, monitoring or care during this time. The IJ existed at: 42 CFR 483.35(a) Sufficient Staff - F725 Scope and Severity J The State Agency (SA) notified the facility Administrator of the IJ on 9/26/23 at 1:15 PM and the IJ template was provided to the Administrator. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.35(a) Sufficient Staff F725 J was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Staffing . revised October 2017 revealed Our facility provides sufficient staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care . During an interview with Registered Nurse (RN) #2 on 9/20/23 at 3:40 PM, RN #2 reported that she was 'usually' the RN Supervisor Monday through Friday of each week from 8:00 AM through 4:30 PM but had worked the cart as the medication/charge nurse on the Transitional Care Unit (TCU) on 9/15/23 due to a staff member scheduled to work had called off work. She confirmed that this left the unit without an RN Supervisor for the day shift on 9/15/23. She stated also that a new resident was admitted by the facility TCU shortly after 4:00 PM on 9/15/23. She confirmed that new admissions required additional time from staff for orientation to their surroundings, audits, monitoring for pain and overall condition and to establish a baseline to determine care needs. She reported that she was relieved by Licensed Practical Nurse (LPN) #3 at 4:30 PM. She stated that during the shift change report she had informed LPN #3 that Resident #1 had not returned from dialysis. RN #2 said she then went to the [NAME] unit to work until 7:00 PM due to staff calling off work. During an interview with LPN #3 on 9/20/23 at 4:52 PM, confirmed that she had been told by RN #2 during shift change report at 4:30 PM on 9/15/23 that Resident #1 had not returned from the dialysis unit. LPN #3 confirmed that she had not been concerned when Resident #1 had not returned by 6:30 PM when she gave shift change report to LPN #1. She stated that she left the facility without contacting the dialysis unit, the Responsible Party (RP) for Resident #1 or the Director of Nurses (DON). During an interview with LPN #1 on 9/20/23 at 5:15 PM, the LPN said that she was not concerned that Resident #1 had not returned from the dialysis unit when she initially assumed responsibility for the residents on TCU between 6:30 PM and 7:00 PM on 9/15/23. She said that on 9/15/23 at approximately 10:00 PM, after she had finished medication administration rounds, she 'realized' that Resident #1 had not returned. LPN #1 stated that she attempted to contact the dialysis unit by telephone without success. LPN #1 described the 7:00 PM - 7:00 AM shift on 9/15/23 as hectic and said she had one CNA assisting her to care for twenty-nine (29) to thirty (30) TCU residents. LPN #1 stated, that between 10:00 PM and 10:30 PM on 9/15/23 There was a new admit coming in and problems with another new resident. She said it was possible that if she had more staff present on the evening of 9/15/23 she would have had more time to give to locating Resident #1. LPN #1 stated, there was a lot going on and we were trying to make it work, She confirmed that after she called the dialysis unit, she did not make any further efforts to determine the whereabouts of Resident #1 or notify the DON or the resident's Responsible Party (RP) of the resident's absence. LPN #1 confirmed that because the resident was unsupervised in the facility van in the facility parking lot she had not received food, fluids, care, medications or monitoring following dialysis treatment, which LPN #1 described as very heartbreaking. On 9/21/23 at 9:48 AM, an interview with LPN #4 revealed that she became aware that Resident #1 was missing from the facility when she was making 'first rounds' shortly after 7:00 AM on 9/16/23 and directly observed that the resident was not in her room. She said she asked LPN #1 where Resident #1 was to which LPN #1 responded I didn't even know she wasn't here till after 10:00 (PM) last night. On 9/27/23 at 1:30 PM, an interview with the DON reported that there was one (1) LPN and one (1) CNA responsible for the care of the residents on each unit of the facility (TCU and West) from 7:00 PM on 9/15/23 through 7:00 AM on 9/16/23. She confirmed that it was possible that more staff on the shift may have led to staff locating Resident #1 sooner. She confirmed that prior to the incident the facility had not scheduled an additional staff member to accompany residents for medical appointments, with the driver being the sole staff member responsible for loading, transporting, unloading, and supervising residents during transportation. She confirmed that an additional staff accompanying Resident #1 for the return to the facility may have prevented the resident being left unsupervised on the facility van. The DON reported that there were two additional CNAs scheduled to work 9/15/23 at 7:00 PM through 7:00 AM on 9/16/23 that had called off work due to testing positive for COVID-19 and were not replaced on the schedule because there was no one available. On 9/27/23 at 5:05 PM, an interview with the Administrator confirmed he had completed a Facility Assessment, which was updated annually, was utilized in staffing decisions. The Administrator stated that staffing needs change often based on need determined by the number and acuity of residents. He reported that the facility did not employ agency staffing. The Administrator said that employees calling off work could sometimes be an issue. He stated that he had not been notified by the DON of a need for additional staff. He stated that if he were made aware of a need for additional staff he could reach out to sister facilities for additional staff to meet the care needs of residents. He confirmed that he had not done so for 9/15/23. He stated that on 9/15/23 the facility could have had more staff and that the staffing for 9/15/23 had not been by design. The Administrator clarified that by design there was supposed to be more staff but that had changed due to staff calling off work due to staff testing positive for COVID-19. Record review of the local hospital Emergency Department (ED) notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure, Rhabdomyolysis, Adult Neglect or Abandonment, and Elevated Blood Pressure Reading. The ED notes included consideration of intravenous fluids avoided due to the resident's diagnosis of End Stage Renal Disease. The EDNP confirmed on 9/27/23 at 4:15 PM, during a telephone interview, that providing assessment and care for Resident #1 on 9/16/23 was important. She stated that the incident was extremely dangerous for Resident #1 and that the resident's health was absolutely compromised. During a telephone interview on 9/28/23 at 11:10 AM, the contracted Licensed Certified Social Worker (LCSW) revealed that she had counseled Resident #1 at or about 5:00 PM on 9/27/23. Following her assessment, she had diagnosed Resident #1 with Acute Reaction to Stress and had recommended monitoring for adverse effects for at least ninety days. The LCSW stated that Resident #1 had reported feeling doomed, anxious, fearful and worried. The LCSW stated, I definitely believe it was detrimental in the way she was frightened and talked about not being provided with the care she needed Record review of the admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive Urgency, Long Term (current) use of Insulin, End Stage Renal Disease, Dependence on Renal Dialysis, Chronic diastolic (congestive) heart failure, Type 2 Diabetes Mellitus, long-term current use of insulin, Dependence on renal dialysis, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident interviews, facility policy review, and record review the facility failed to ensure significant medication (anti-diabetic, anti-hypertension, bronchitis, and pain management medications) were administered to prevent discomfort or complications for one (1) of four (4) residents reviewed, Resident #1. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. On 9/15/23 the facility failed to remove the resident from the facility van following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair in the facility van, unsupervised and without significant medications including insulin, respiratory and hypertensive medications for sixteen (16) hours and fifteen (15) minutes without the staff awareness. The facility's failure to transfer Resident #1 inside the facility and administer medications as ordered by the physician after hemodialysis placed Resident #1 in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/15/23, when the facility abandoned Resident #1 on the facility van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis and did not receive medications as ordered by the physician. The IJ and SQC existed at: 42 CFR 483.45(f)(2) Residents are free of any significant medication errors - F760, Scope and Severity J'. The SA notified the facility's Administrator of the IJ and SQC on 9/26/23 and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.45(f)(2) Residents are free of any significant medication errors - F760 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Medication Administration-General Guidelines with a current revision date, August 25, 2014, revealed, Medications are administered as prescribed in accordance with good nursing principles and practices .Medications are administered within 60 minutes of scheduled time, except before or after meals order, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration scheduled for the facility. A record review of the Facility Investigation, dated 9/19/2023, revealed, Incident: During shift report on 9/16/2023 at approximately 7:00 am (AM), the night shift informed the oncoming shift that the resident did not return from dialysis on 9/15/2023. A record review of a written statement by Licensed Practice Nurse (LPN) #1 revealed, on 9/15/23 she received report that patient (Resident #1) had not returned from dialysis. After completing pm (PM) med (medication) pass, the resident had still not returned. At around 10 (PM) or so I tried to call (Professional Name Dialysis Center) with no answer. Reported told day shift nurse that she had not returned from dialysis . A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed the following physician orders for blood pressure medication that was scheduled from 7 PM until 10 PM: Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed her diabetic medication (insulin) and accucheck on 9/16/23. She also missed accucheck parameter monitoring with orders to report to the physician if the blood glucose was less than 60 mg/dl (milligrams/deciliter) or greater than 400 mg/dl. A record review of the Order Summary Report also revealed Proventil HFA (bronchitis) was missed for Resident #1's breathing. In an interview on 9/20/23 at 5:15 PM, with LPN #1 revealed that she worked 9/15/23 from 7:00 PM until 9/16/23 at 7:00 AM. LPN #1 confirmed that Resident #1 did not receive her accucheck (blood sugar checks) on 9/15/23 in the evening and on 9/16/23 in the morning. Resident #1 did not receive her significant medications, such as blood pressure, bronchitis inhaler, and insulin. LPN #1 stated that since Resident #1 did not receive her blood pressure medications, a bronchitis inhaler or accucheck with insulin, this could have caused Resident #1's blood pressure to be elevated and caused a hypertensive crisis. Since the resident did not receive her inhaler, she could have been experiencing shortness of breath. Resident #1's accucheck was not checked nor was her insulin given, since neither was performed, she may have been hypo or hyperglycemic (high or low blood sugar levels), which would have been dangerous to her health. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 confirmed on 9/15/23, the following medications were coded (documented) as 3 (resident absent from home) and not administered for blood pressure Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. Record review of Resident #1's [DATE]/1/23 - 9/30/23 revealed on 9/16/23, the following medications were coded (documented) as 3 (resident absent from home) and not administered: Insulin Detemir Solution, Accu check, and Proventil for bronchitis. Record review of Resident #1's [DATE]/1/23 - 9/30/23 revealed the following medications were coded (documented) as a 3 (resident absent from home) on 9/15/23: Lidocaine-Prilocaine cream to left hand and Lyrica for Neuropathy. Ultram (Tramadol) was ordered every 12 hours as needed for pain. Resident #1 received Ultram daily from 9/1/23 - 9/14/23. Three of these 14 days, the resident received Ultram twice a day. The facility Medical Director reported during an interview on 9/26/23 at 10:20 AM, Missed medications are always a concern; that, among other things, is the reason I wanted her to go to the emergency room (ER), so they could look at her, check labs, etc. The Medical Director stated there was potential for serious complications for Resident #1, especially with her comorbidities. An interview with the Director of Nurses (DON) on 9/26/23 at 1:35 PM, revealed that on 9/15/23 at approximately 3:30 PM, the Transportation Aide (TA) left Resident #1 in the facility van and was found on 9/16/23 at approximately 7:45 AM. The DON stated that the resident not receiving her significant medication for blood pressure, diabetes, and an inhaler could have caused serious injury or impairment. She stated that the failure of the facility to ensure the resident received the morning dose of insulin and monitoring of the blood glucose for Resident #1 on the morning of 9/16/23 could have resulted in the resident experiencing signs and symptoms of hyperglycemia. The DON confirmed that failure to monitor the resident dialysis graph/shunt site could have resulted in bleeding at the site, which could have resulted in the resident losing blood or hemorrhaging. She stated that monitoring the site following a dialysis appointment was very important for the resident's safety. Record review of the admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive, Insulin-Dependent, Dependence on Renal Dialysis, Chronic Diastolic (Congestive) Heart Failure, Type 2 Diabetes Mellitus, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score is 07 indicating Resident #1 had severe cognitive impairment. Section J revealed the resident had pain frequently. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the removal plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.