**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident interviews, observations, record reviews, and facility policy and procedure reviews, the facility failed to provide supervision to prevent the elopement of a delusional resident who voiced and was identified by the facility as being at high risk for elopement. Resident #1 was one (1) of six (6) Residents that the facility had identified as at risk for elopement. (Resident #1) The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) Past Non-Compliance (PNC) which began on [DATE], when the facility allowed Resident #1 to leave the facility through his disassembled bedroom window unsupervised and unwitnessed. Resident #1 was found several miles away by local Law Enforcement at a store. He was assumed by the facility to be away from his bedroom for approximately five and a half (5.5) hours. Resident #1 was last seen by Certified Nursing Assistant (CNA #1) on [DATE] at approximately 12:30 A.M. and was not seen again until his return to the facility at approximately 6:00 A.M. The facility's failure to provide supervision placed Resident #1 and other residents identified elopement risk placed the residents with likelihood of serious injury, harm, impairment, or death. On [DATE] at 2:00 P.M. the SA informed the facility's Administrator (ADM) of the Immediate Jeopardy (IJ) and provided the IJ Template. The facility provided an acceptable Removal Plan-Past Non-Compliance (PNC) on [DATE], in which the facility alleged all corrective actions were completed to remove the IJ (PNC) on [DATE], prior to the SA entering the building on [DATE]. The (SA) validated the Removal Plan on [DATE]-[DATE] and determined the IJ (PNC) was removed on [DATE], prior to SA's entering the building on [DATE]. The Scope and Severity (S/S) for F689-Accidents/Hazards/Supervision, was lowered from a K to an E due to the facility being recently cited for the same deficiency on [DATE]. Findings Include: The facility policy and procedure titled Wander Management, Monitoring System and Resident Elopement Protocol dated Revised [DATE] Reviewed 01/2023 read: To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility. It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents, so identified, will have these issues addressed in their individual care plans. Interview on [DATE] at 9:50 A.M. with the facility Administrator (ADM) revealed that Resident #1 had made an attempt to leave the facility on [DATE] with staff following close behind him which prevented Resident #1 from leaving the front porch of the facility after he voiced that he needed to leave to get a job. On [DATE] Resident #1 had a Brief Mental Status Score (BIMS) of 14 which indicated that he was cognitively intact, but he did voice delusional statements such as he needed to return to his job and/or report for a job interview. Resident #1 had written large documents in a note book that he explained to staff were his resume' documents and that he needed to leave to take his resume' with him to job interviews. The ADM stated that Resident #1 had been admitted to the facility from another nursing home. The ADM stated that Resident #1 had a known history of wandering and was an elopement risk. The ADM stated that Resident #1 was identified as one (1) of six (6) residents living in the facility that were wanderers and high risk for elopement. The ADM stated that Resident #1 had been given a wander guard to sound when Resident #1 got close to the exit doors. The ADM stated that the wander guards do not work on the windows, but on [DATE] after midnight that Resident #1 left the facility through his disassembled bedroom window and he had taken his wander guard off and left it on his bedroom dresser. The ADM provided pictures made with her cell phone of the disassembled window, a broken and bent window screen, and the window taken completely out of its frame and sitting on top of room air conditioner inside Resident #1's private room. The ADM stated that when Resident #1 eloped undetected and unsupervised from the facility on [DATE] after midnight, he took with him a roll of toilet tissue, his note book of writings/resume', an extra pair of black tennis shoes and a black hooded sweat shirt that he had wrapped around his body as a make-shift back pack. Resident #1 was wearing a white T-shirt, olive green cargo pants, eye glasses and blue tennis shoes. Resident #1 was last seen by a Certified Nursing Assistant (CNA#1), at 12:30 A.M. on [DATE] and at approximately 2:00 A.M. on [DATE] LPN #1 discovered that Resident #1 had disassembled his bed room window and had left out his window unsupervised and undetected. The local Law Enforcement contacted the ADM at approximately 5:44 A.M. that Resident #1 was at the Dispatch Office waiting for the facility to come and pick him up. The ADM and the DON drove to the Dispatch office and obtained Resident #1 and brought him back to the facility at approximately 6:00 A.M. The DON and nursing staff assessed Resident #1 and found him to be delusional but not physically injured. The facility placed Resident #1 on one to one (1:1) close observation with documented visual accountability every 15 minutes. The wander guard was re-placed on Resident #1 and his bedroom window was re-paired and fastened with screws drilled into the frame by the Maintenance Department. Resident #1 has remained on 1:1 since his return to the facility and his 1:1 will remain in place until he is discharge on [DATE] to a locked unit at another facility. Interview and observation of Resident #1 on [DATE] at 10:15 A.M. revealed Resident #1 made no attempts at conversation. Resident #1 stated that he was getting in his exercise. Observation of his room revealed that he was in a private room with no roommate, the bedroom window was securely attached and in working order. The window would not open all the way but provided approximately six (6) inches of an opening for fresh air. The screen on the outside of the window was attached. Resident #1 had an over bed table in front of a straight back chair that contained a note book and a pen for writing. The note book appeared to be filled with Resident's personal writings. The ADM demonstrated to surveyor how the window was now securely screwed in to the frame of the window and that it would no longer lift out of the frame. The windows were large and were designed to slide from side to side in order to open. The windows were currently secured as not to slide from side to side but only open approximately six (6) inches. Resident #1 was not present when the ADM demonstrated the current status of his bedroom window. Resident #1 was walking all about the facility with a staff member. Interview on [DATE] at 10:30 A.M. with the Director of Nursing (DON) revealed that she had ridden to the Dispatch Office with the ADM to pick up Resident #1 on [DATE] at approximately 6:00 A.M. The DON stated that the weather conditions on [DATE] were not good and that it was raining and hot. Upon returning Resident #1 to the facility on [DATE] at approximately 6:00 A.M. the DON, along with other nursing staff, LPN #1 and RN Supervisor #2, assessed Resident #1 and all identified wanderers and found no physical injuries and wander guards were in place and functioning properly. The DON stated that she over saw the verification and accountability of all residents per the census of 149 residents. DON stated that Resident #1 had been assessed upon his admission to be at high risk for elopement and a wander guard was put in place. The DON stated that she re-assessed Resident #1 on [DATE] and documented his High Risk for Wandering on the Wander Data Collection form. The DON stated that the Maintenance department had been at the facility on [DATE] and had secured the bedroom window of Resident #1's room prior to 7:00 A.M. on [DATE]. The DON stated that she also re-assessed Resident #1 for his high risk for wandering again on [DATE]. The DON confirmed that on [DATE] the Quality Assurance (QA) committee members met and discussed the events of Resident #1's elopement. The DON stated that all corrections had been completed on [DATE]-[DATE]. The DON stated that Resident #1 had been on 1:1 close observation with a staff 24/7 since the elopement on [DATE] and would remain on 1:1 until his discharge to a locked unit at another facility. The DON stated that the immediate dangers of the elopement were corrected on [DATE] when Resident #1 was returned safely, placed on 1:1 close observation with a new functioning wander guard system and the window of Resident #1's room secured and repaired by Maintenance. The facility continued with in-servicing of staff and assessing of residents, and the first QA meeting was on [DATE]. The Psychiatric Nurse Practitioner came to the facility on [DATE] and re-assessed Resident #1 and wrote orders to continue the 1:1. Interview on [DATE] at 2:40 P.M. with Certified Nursing Assistant (CNA #1) revealed that she was a new employee to the facility that was hired on [DATE]. She stated that on the night of Resident #1's elopement she and two (2) other CNA's were working on the unit and two (2) LPN's. CNA #1 stated that there was plenty of staff working on the unit. She stated that Resident #1 was his normal self and was not acting like he was going to leave and he had not voiced anything unusual to her. Resident #1 was assigned to her and she had been checking on him throughout the night. CNA #1 saw Resident #1 sleeping in his bed at 12:30 A.M. on [DATE] in his private room. Then the LPN #1 went at 2:00 A.M. to check on him and he was gone. The entire staff began to look for Resident #1. CNA #1 stated that Resident #1 had not expressed to her that he wanted to leave the facility. CNA #1 stated that Resident #1 eloped through his bed room window. Interview on [DATE] at 3:28 P.M. with the Licensed Social Worker (LSW) , revealed that she had been the LSW at the facility during Resident #1's admission. LSW stated that Resident #1 had delusions and that he had voiced exit seeking behaviors. Resident #1 believed that he needed to get a job and that he must get a job to survey the land and water. The LSW stated that Resident #1 had made an attempt to leave the facility on [DATE] when he left out the front door by pushing the door open as another resident entered from the front porch. There were staff members and the receptionist with him and they eventually were able to talk resident into coming back into the building. The LSW stated that she updated the incidents on Resident #1's care plan and had obtained an evaluation at a geriatric psychiatric facility as a result of his exit attempt on [DATE]. The psychiatric facility came and picked Resident #1 up to transport him to the psychiatric facility and while in transit Resident #1 became combative and the transport van turned around and brought Resident #1 back to the facility on [DATE]. The LSW provided the care plan documentation outlining the events of [DATE] and [DATE]. The LSW verified that the facility staff had been attending in-services since the elopement attempt on [DATE]. The LSW stated that Resident #1 is active and strong bodied and walks several miles per day throughout the facility for exercise and he continues to believe he has a job. The LSW stated that Resident #1 had a diagnosis of frontal lobe traumatic brain injury and that he does not have the ability to reason and he does have a delusional thought process. The LSW stated that Resident #1 would better benefit on a locked unit with memory care. The LSW stated that the psychiatric facilities would not consent to admit Resident #1 because he would not give his consent for treatment. The LSW stated that Resident #1's family do not want Resident #1 to be discharged and the family does not come to visit the facility often but they do call Resident #1 and he does talk to family on the telephone. The LSW stated that the family was in agreement with his discharge to a locked unit with memory care. The LSW stated that Resident #1 will remain on 1:1 until his anticipated discharge on [DATE]. LSW stated that she updated the wandering information and high risk for elopement residents list and made sure that the books with their information were all updated and current as well as accessible to all staff. Interview and observation on [DATE] at 4:00 P.M. with Resident #1, revealed that he was sitting in his private room with his feet up in a reclining chair watching television. Resident was dressed in olive green cargo pants with black tennis shoes and a black t-shirt. Sitting across from Resident #1 in a chair with an over bed table was a Certified Nursing Assistant (CNA) charting on the resident every thirty (30) minutes. Resident #1 stated to surveyor that he was watching a preacher on the TV but was unable to recall what the preacher's name was or what the sermon was about. Resident's speech was pressured and rapid and he was talking about his resume' and his job interviews that he had arranged. Resident's thoughts were loose and his sentences were disconnected. He rapidly changed from subject to subject and his thought process was disconnected from his answers. The writings were not comprehendible. On [DATE] at 4:00 P.M. Resident #1 told surveyor that he needed to leave in order to get to work. Resident #1 presented as ambulatory and agile. Resident had an agenda and he expressed that he was leaving. Resident was unable to recall ever being in an accident. Resident said that his brain had been cut open and taken out and cleaned and sewed back in his head. Resident rambled on in a rapid and repetitive manner. Resident was oriented to self, but was not oriented to situation, time, place, or date. Interview on [DATE] at 5:30 P.M. with the evening Receptionist #1, revealed that she worked the front desk and was in charge of the front door exiting and entering. She worked Monday -Friday 5:00 P.M.-7:00 PM and she worked weekends 8:00 A.M. -7:00 P.M. She stated that she was at the front desk on [DATE] at approximately 6:00 P.M. when Resident #1 attempted to leave the facility. She stated that she attempted to hold the door shut when Resident #1 pushed her and the door open. Resident #1 got out on the front porch but staff were able to distract him and coax him back in to the building. She stated that Resident #1 walked constantly and that he walked approximately 5-10 miles per day throughout the facility. Interview on [DATE] at 7:07 P.M. with Registered Nurse (RN#1). She stated that she was the supervisor for the night shift at the facility on [DATE] when Resident #1 eloped. She stated that there were plenty of staff in the building and that the unit that housed Resident #1 contained three (3) CNA's and two (2) LPN's and one (1) RN supervisor. She stated that she was called to report Resident #1 was missing at approximately 2:00 A.M. on [DATE]. She stated that she saw the window in his room removed from the frame and the screen broken out and Resident #1 was no where in the facility. The entire staff immediately began searching for Resident #1. RN#1 stated that she was at the facility when Resident #1 was returned on [DATE] at approximately 7:00 A.M. RN #1 stated that the weather conditions on [DATE] were rainy and hot. RN #1 stated that Resident #1 had a fixed delusion that he was going to leave and go to work. When Resident #1 returned to the facility she assessed him and other residents. RN#1 began in-services with staff on [DATE]. All residents were accounted for and unharmed. Interview on [DATE] at 8:55 A.M. with Registered Nurse (RN#3) revealed she was responsible for compiling the care plans for all the residents along with the LSW. She stated that she and the LSW revised and updated Resident #1's care plan. She stated that all staff have access to the care plans and that the care plan information was available to the CNA's through the care giver guide that the CNA's maintained on each unit. RN#3 confirmed that after the failed elopement attempt of Resident #1 on [DATE] the care plan was updated and after his combative episode on the transportation van, the Care Plan of Resident #1 was updated and again after the elopement on [DATE] the Care Plan of Resident #1 was updated. Interview on [DATE] at 9:15 A.M. with Maintenance revealed that he was called to the facility on [DATE] in the early morning hours and told that Resident #1 had left the facility through the window of his room. He came to the facility at approximately 2:30 A.M. and assisted with the search of Resident #1. The weather was rainy and visibility was poor. The maintenance man was surprised to see the window taken out of the frame and the screen bent back. Maintenance stated that he never would have thought that someone would be able to remove the window from the frame and leave the facility. Maintenance stated that Resident #1 was brought back to the facility between 6:00 A.M. and 7:00 A.M. on [DATE]. Maintenance had placed the window back and screwed the frame into the wall preventing the window to slide out of its track. Resident #1 was placed on 1:1 with staff at his side 24/7. Interview on [DATE] at 9:30 A.M. with Licensed Practical Nurse (LPN #1) revealed that she had worked at the facility for about four (4) years as the night LPN. She stated that Resident #1 would wake up during the night several times and come up to the nursing station asking for snacks to eat. LPN #1 stated that she thought it odd that he had not been up to the desk asking for his snacks so about 2:00 A.M. she took a snack to Resident #1's room and found him gone and the window removed. LPN #1 stated that there were plenty of staff working at the facility on [DATE] during the evening shift. LPN #1 called the ADM and DON and the Resident's Representative and the nurse practitioner to report the elopement. LPN #1 stated that CNA #1 had reported seeing Resident #1 in his bed sleeping at approximately 12:30 A.M. and that CNA #1 was the last person to see him. LPN #1 stated that Resident #1 was returned to the facility at approximately 6:30 A.M. on [DATE] with the ADM and the DON. The local Sheriff 's office had found Resident #1. It was approximately 5.5 hours that Resident #1 was reported to be missing from the facility. No one saw him leave and no one knew what time it was when he eloped. Interview and observation on [DATE] at 2:30 P.M. with Receptionist #2 of the front desk and front door of the facility revealed that she sits at the front desk monitoring the front door from 8:00 A.M. - 5:00 P.M. Monday through Friday and she had the high risk for elopements book at the desk with her and she knew the names and faces of all six (6) residents on the list. Receptionist #2 showed surveyor the high risk for elopement binder with all the information on all six (6) wanderers. The wander guard system was tested with a wander guard and it sounded loudly when it reached the front door. Wander guard system intact and working properly. The front door was observed to be locked and the Receptionist #2 was observed to push a button or use a code on a punch pad to open the door to let visitors and residents and staff in and out. No resident was observed to use the punch pad entering a code to release the door. Only staff were observed using the punch pad to enter and exit. Record review of the Face Sheet of Resident #1 revealed that he had an admission date to the facility of [DATE]. Resident #1's admitting diagnoses were Traumatic Subdural Hemorrhage without loss of Consciousness; Epilepsy; Frontal Lobe and Executive Function Deficit; Mild Cognitive Impairment; Confusion Arousals; Difficulty Walking; Lack of Coordination; Muscle Weakness; among other diagnoses. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated he was not cognitively impaired. Record review of the facility's assessment for Risk of Elopement dated [DATE], [DATE], and [DATE] revealed that Resident #1 was assessed as a High risk for Wandering. Record review of the psychiatric Nurse Practitioner's assessment of Resident #1 dated [DATE] revealed: Resident is referred by staff for severe confusion, delusions, and wandering/leaving facility. The note indicated Multiple redirections required throughout visit but thoughts return to severe delusions .I cannot recommend that 1:1 observation be discontinued at this time as risk of elopement remains high. Recommendations: Add diagnosis of Vascular Dementia with Psychotic disturbance. Record review of the care plan for Resident #1 dated [DATE] revealed that he was care planned as at high risk for elopement/wanderer r/t (in reference to) that he wanders aimlessly throughout the facility. Interventions on the care plan documented on [DATE] Resident presented with exit seeking behaviors, Resident continues attempts to elope. Wander evaluation scored as high risk. [DATE] While a resident was entering the building, this resident pushed the receptionist and exited the building. Staff remained with resident the entire time. Resident refused to come back in the door. Resident sat on bench accompanied by nurse after calming down. [DATE] -SW was notified the resident was unable to receive treatment from Freedom behavior due to the resident being combative and transportation having to stop during transport. Encourage me to participate in activities; Observe for signs of agitation, pacing, repetitive verbalizations of wanting to leave/go home, restlessness. IJ Removal Plan On [DATE] at 2:00 P.M. the State Agency (SA) notified the facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this removal plan. Brief Summary of Events On [DATE] at approximately 2:00 A.M. it was discovered that Resident # 1 exited the building through his window by disassembling the window from the frame. Resident #1 had a wander guard on which he removed prior to exiting. The wander guard was properly functioning but does not alarm when removed nor if exiting through a window or other means of egress. The facility failed to provide supervision to prevent the elopement of Resident # 1, who was deemed an elopement risk and left the facility unattended. This failure allowed Resident # 1 to be away from the facility unnoticed and unsupervised on [DATE] from 12:30 A.M. until 5:44 A.M., when the facility was alerted by the Sheriff's department that the resident had been located. This was approximately 5.5 hours after Resident #1 was last observed in the facility by Certified Nursing Assistant (CNA) #1. The facility picked up Resident #1 at the local sheriff dispatch office at 5:51 A.M. Corrective Actions 1. On [DATE] at 2:00 A.M., LPN (Licensed Practical Nurse) #1 made rounds and Resident #1 was not present in his room and his window was disassembled. 2. On [DATE] at 2:02 A.M., LPN #1 initiated a facility elopement drill. Resident #1 was not located in the facility and all residents were accounted for. 3. On [DATE] at approximately 2:19 A.M., the Administrator was notified by LPN #1 of Resident #1 missing from facility. 4. On [DATE] at approximately 2:24 A.M., the Director of Nurses was notified by the Administrator of Resident #1 missing from the facility. 5. On [DATE] at approximately 2:25 A.M., the local Police Department was notified by RN (Registered Nurse) Supervisor #1 of Resident #1 missing from the facility. 6. On [DATE] at approximately 5:44 A.M., the facility Administrator was notified by the Sheriff Department that Resident #1 had been located. 7. On [DATE] at approximately 5:51 A.M., the Administrator and Director of Nurses picked up Resident #1 at local dispatch office. 8. On [DATE] at approximately 6:00 A.M., the RN (Registered Nurse) Supervisor #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns. 9. On [DATE] at about 6:00 A.M., the DON oversaw verification of all residents in facility using census. The census in the facility was 149 with 2 residents in the hospital. All 149 residents were accounted for or verified. 10. On [DATE] at approximately 6:15 A.M., Resident #1 was placed on 1:1 monitoring. 11. On [DATE] at approximately 6:15 A.M., the wander guard bracelet was verified to work properly by checking function with door alarm by DON, and then placed on Resident #1's left wrist. 12. On [DATE] at approximately 6:20 A.M., the facility staff was interviewed by the Administrator to determine the timeline of events leading up to Resident #1's exit of facility. Statements were collected. 13. On [DATE] at approximately 6:30 A.M., staff present in the facility during the time of Resident #1 exit, received immediate in-service by the DON and Administrator on the Elopement procedures, Abuse/Neglect, Vulnerable Adult Act and Rounding. 14. On [DATE] at approximately 6:40 A.M., all required state agencies were notified of Resident #1 elopement. 15. On [DATE] at approximately 7:00 A.M., Maintenance assessed Resident # 1's window. Window glass appeared intact and window stopper in place. Maintenance reassembled window and inserted additional safety mechanisms to prevent window from being disassembled in the future by Resident #1. 16. On [DATE] approximately 7:15 A.M., the LPN #1 initiated facility-based incident reporting on Resident #1. 17. On [DATE] at about 7:20 A.M., Maintenance initiated an audit of all 1st floor windows to ensure they are intact and functioning properly. All windows were intact and functioning properly. Maintenance initiated adding additional safety mechanisms to prevent window from being disassemble from frame. 18. On [DATE] at approximately 07:27 A.M., the Nurse Practitioner (NP) was notified by the RN Supervisor #1 of Resident #1 elopement and return to the facility. 19. On [DATE] at approximately 07:27 A.M., Resident #1 Responsible Party was notified by the Administrator that Resident #1 had been returned to the facility. 20. On [DATE] at approximately 08:36 A.M., licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. 21. On [DATE] at 7:04 P.M., the DON completed a post Elopement incident. Resident #1 remains high risk for Elopement. 22. On [DATE] at approximately 08:21 A.M., the Social Services Director followed up on resident's psychosocial needs and will continue for the next 72 hours. 23. On [DATE] at approximately 12:00 P.M., the Social Services Director reviewed the wander and elopement binders to ensure all are reflective of results. 24. On [DATE] at approximately 12: 43 P.M., Resident #1 was assessed by Psychiatric NP. 25. On [DATE] at approximately 2:00 P.M., a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. 26. On [DATE] at approximately 6:00 P.M., the Assistant Director of Nursing audited current high-risk wander patients to review orders and care plans for accuracy. There are currently six (6) wander patients. 27. On [DATE] at approximately 7:25 P.M., the RN Supervisor #2 performed an elopement drill to review and educate night shift on policies and procedures on elopement. 28. On [DATE] at approximately 11:15 P.M., the RN Supervisor # 1 performed an elopement drill to review and educate evening shift on policies and procedures on elopement. 29. The facility could not anticipate that the resident would dissemble his window and leave the facility. The facility feels like the IJ's were removed on [DATE]. The facility alleged that all activities to remove the IJ were completed on [DATE] prior to the SA entering the building on [DATE]. State Agency (SA) Validations were made onsite during the complaint investigation, CI MS #25237. On [DATE], the SA validated through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on [DATE] prior to the SA entering the building on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dialysis center staff interviews, facility staff interviews, resident interview, record review, and facility policy review, the facility failed to ensure the right to be free from neglect when the facility failed to transport a dialysis resident to a scheduled surgical procedure to ligate (to tie up or close off an artery) an arteriovenous (AV) fistula scheduled on 03/21/24 resulting in the resident being admitted to the hospital on [DATE] with a bleeding aneurysm of the AV fistula requiring a blood transfusion with (4) four units of blood for one (1) of four (4) residents on dialysis reviewed. (Resident #2) The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 03/21/24, when the facility neglected to transport Resident #2 to his appointment for a scheduled surgical procedure. The facility's failure to transport this dialysis resident to the appointment placed this resident and other residents in a situation which was likely to cause serious injury, serious harm, serious impairment, or death. On 04/03/24 at 5:31 PM, the SA informed the Nursing Home Administrator (NHA) of the IJ and SQC and presented the IJ Template to the Administrator. The facility submitted a Removal Plan on 04/04/24, at 7:10 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 4/04/2024 and the IJ removed as of 4/05/2024. The SA validated the Removal Plan on 04/05/2024 and determined the IJ was removed on 4/05/24, prior to exit; therefore, the scope and severity for Abuse and Neglect (F600) was lowered from a J to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Abuse Prohibition, revised 11/07/2023, revealed this protocol was intended to assist in the prevention of neglect. Each resident has the right to be free from neglect. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services that are necessary to a resident to avoid physical harm, mental anguish, or emotional distress. Review of a statement on facility letterhead dated 04/04/24 and signed by the Administrator revealed the facility has no policy related to appointments. Review summary of an anonymous complaint the State Agency (SA) received on 03/25/24, revealed Resident #2 is a dialysis patient who resides at the nursing home. Resident #2 needed a life sustaining surgery to prevent his dialysis access from rupturing causing an estimated (4) four-pint blood loss. The facility was made aware of the surgery date and time and reported they would take the resident to the surgery. Record review of the Hemodialysis communication form for Resident #2 dated 03/18/24, revealed, Follow-up includes: appointment on 03/19/24 at 12:00 PM to have catheter placement to femoral artery and surgery on Thursday 03/21/24 to have ligation of the access. Record review of an appointment card for Resident # 2 in the medical record, revealed date 03/21/24 Ligate Access. Time TBA (to be announced). Record review of nurse's notes by an agency Licensed Practical Nurse (LPN) #4 dated 03/18/24 at 3:45 PM, revealed Resident #2 arrived from dialysis, did not receive dialysis today due to condition of access site. Site is to be monitored. Resident has an appointment tomorrow (03/19/24) for a catheter placement. Record review of Nurses Notes for Resident #2, dated 03/22/24 at 6:25 AM, revealed the resident noted in wheelchair with active bleeding noted from right arm from old dialysis site. Staff applied pressure to site. An ambulance was called and arrived and transported the resident to hospital. Record review of the physician's notes from the hospital revealed Resident #2 was admitted to the hospital on [DATE] with principal diagnosis of an Aneurysm of Arteriovenous (AV) Dialysis Fistula requiring four (4) units of blood related to acute blood loss anemia secondary to the ruptured aneurysm of AV dialysis fistula. The note documented the resident's blood pressure was 72/43 due to acute blood loss. An interview with Resident #6 on 04/05/24 at 9:50 AM, revealed he is Resident #2's roommate and also goes to dialysis every Monday, Wednesday and Friday. He revealed he knew Resident #2 had an appointment for a procedure on March 19th (03/19/24) and also had to have surgery on his arm on the following Thursday. He stated, I know Resident #2 went to the appointment on Tuesday the 19th, but not sure why he did not go on the following Thursday. Resident #6 also revealed on the morning his roommate went to the hospital, the staff had gotten him up for dialysis and after a little while he looked down at the floor where his roommate was sitting and saw blood dripping on the floor and there was a lot of it and confirmed he called for help and the staff worked on Resident #2 until the ambulance came. Review of section C of the Minimum Data Set (MDS) for Resident #6 with an Assessment Reference Date (ARD) of 01/09/24 revealed the Brief Interview for Mental Status (BIMS) score was a 15 indicating the resident was cognitively intact. An interview with agency LPN #4 on 04/03/24 at 11:00 AM, revealed she was assigned to Resident #2 on 03/18/24, she stated she remembered when he returned from dialysis that he had two appointment cards and paperwork for the appointments on March 19th (03/19/24) and one for March 21st (03/21/24). She revealed she works for a staffing agency and was unaware of the scheduling process, but she gave the information regarding the appointments to the charge nurse on duty and she filled out the appointment forms. An interview with Registered Nurse (RN) #3 on 04/03/24 at 3:00 PM, revealed on the evening of 03/18/24 around 5:30 PM the agency LPN #4 handed her the appointment cards and paperwork sent from dialysis for Resident #2. She revealed she filled out an appointment sheet for 03/19/24 at 12:00 PM and also filled out a form for 03/21/24 asking the Appointment Scheduler to get the time of the appointment clarified because there was no time listed on the card. She confirmed she did not put a physician's order for the 03/21/24 in the computer because it had to be clarified. She stated she placed the forms and appointment cards in the appointment folder and passed the information to the oncoming nurse to follow-up. She also stated she also copied the appointment cards and placed them in the medical records box. She stated when she returned to work on the 03/19/24, Resident #2 was out of the building for his first appointment scheduled, so she knew that the Appointment Scheduler got the appointment forms. RN #3 confirmed she did not personally follow-up to ensure the appointment time was clarified and scheduled for 03/21/24 for Resident #2 but she checked the appointment folder, and the form was not there. She also stated the dialysis clinic was closed at the time she was given the appointment information for Resident # 2, or she would have gotten the clarification for the order. Review of the March 2024 Order Summary Report for Resident #2 revealed there was no physicians order for the surgical procedure scheduled for 03/21/24. An interview with the admission Coordinator/ Appointment Scheduler on 04/03/24 at 11:15 AM, revealed she scheduled the transportation for Resident #2 on 3/19/24 because she was notified by the dialysis clinic of the appointment at 12:00 PM on 03/19/24, but stated she was not notified of any appointment on 3/21/24 to repair the right arm. Review of the appointment calendar for 03/21/24 with the admission Coordinator/ Appointment Scheduler revealed there were no appointments scheduled for Resident #2 for 03/21/24. She also revealed she did not have any of the appointment forms turned in for March, only the calendar logs that she wrote down for the schedule. She stated that she shreds the appointment forms at the end of each month. She also revealed that Resident #2's niece called her 03/19/24 asking her about Resident #2's surgery for his arm and she informed the niece that she was unaware of any surgery scheduled. The admission Coordinator/ Appointment Scheduler was asked if she followed up with dialysis clinic regarding the niece's inquiry about his surgery to his right arm and she stated she informed the niece to let her know if she finds out anything. A phone interview with the dialysis clinic Office Coordinator/LPN #1 on 04/03/24 at 12:15 PM, revealed she sent the dialysis communication form and the two appointment cards back to the facility. She also revealed she called the facility on 03/18/24 in the evening and spoke with the Appointment Scheduler and gave specific instructions and times for both of the appointments on 03/19/24 at 12:00 PM and also for 03/21/24 at 11:30 AM. She revealed she informed the the Appointment Scheduler of the importance of Resident #2 not missing either of the appointments. She revealed she was on the speaker phone and had a witness to the phone call, the Administrative Secretary #2, and the dialysis RN #3. She revealed it is customary for the clinic to call the facilities to ensure they received the paperwork sent back to the facility with the residents. A phone interview with Administrative Secretary #2 at dialysis, on 04/03/24 at 12:20 PM, confirmed she was on the call with Office Coordinator/LPN #1 as a witness to the instructions given to the facility. She confirmed Appointment Scheduler was the staff on the phone at the nursing facility and she was informed of the appointments and times for the appointments 03/19/24 and 03/21/24 and specific instructions for the procedures. Review of the dialysis nurses note dated 03/18/24 by the dialysis Office Coordinator/LPN #1 at 1:43 PM, revealed Resident #2 came to clinic today blood noted on sleeve of shirt. Access was looked at several open areas noted, and small amount of blood noted. Access is pulsatile (pulse detected). The decision was made not to use dialysis access d/t (due to) risk of possible rupture. Informed the surgeon that a significant change in the appearance and size of access from previous visit. An appointment was already made for 03/19/24 at 12:00 PM for catheter placement. Surgery scheduled Thursday 03/21/24 for ligation surgery. The resident's Nephrologist was made aware of condition of access and stated to inform staff and nursing home to call 911 and apply pressure if he bleeds. The Appointment Scheduler at the facility was informed that literature and appointments were sent by the patient. She stated she will let the unit manager be made aware. I repeated several times how important it is for patient to keep the appointments. Record review of dialysis nurses note dated 03/18/24 at 2:51 PM by the dialysis RN #3 revealed, Asked Secretary to call nursing home and make sure they have arranged for Resident #2 to go to catheter appointment on 03/19/24 at 11:30 at hospital and again at 11:30 AM on 03/21/24 for his appointment with surgeon. I was standing next to the secretary when she made the call and heard her speaking with the Appointment Scheduler, who confirmed that she knew about both appointments and was making sure Resident #2 was on their schedule to be transported. An interview with RN #2 on 04/03/24 at 1:00 PM, revealed on 03/18/24 she was notified by the Appointment Scheduler that Resident #2 was scheduled to have a surgical procedure to the fistula site and have a catheter inserted to the groin site. She revealed she was informed by the Appointment Scheduler about the concerns from dialysis of potential risk for hemorrhage from the right arm fistula site and that the clinic was sending a tourniquet to apply to arm if bleeding occurs. She revealed she was unaware why Resident #2 did not go to the procedure on the 03/21/24. During an interview with the Administrator on 04/04/24 at 6:45 PM, she revealed the root cause of Resident #2 missing his scheduled appointment on 03/21/24 was related to the failure of staff to follow-up on a scheduled time for the procedure. Review of the admission Record the facility admitted Resident #2 to the facility on [DATE] with diagnoses of End-Stage Renal Disease and Dependence on renal dialysis. Review of the MDS for Resident #2 with an ARD of 03/22/24, revealed Entry/discharge: Discharge -return anticipated. Removal Plan On 04/04/2024 at approximately 8:30 AM, the Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication. On 04/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received Immediate Jeopardies. On 04/04/2024 at approximately 10:00 AM, the Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff will be allowed to return to work without completing. On 04/04/2024 at approximately 11:25 AM, the Administrator held a one-to-one in-service with admission Coordinator on the appointment scheduling process to include communication, scheduling and following up on appointments. On 04/04/2024 at approximately 12:30 PM, the admission Coordinator conducted an audit of current dialysis patients to review for appointments by contacting the dialysis center and verifying any outside appointment to ensure facility followed up correctly. There are currently twelve (12) dialysis patients. All appointments were followed up. On 04/04/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. On 04/04/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 04/04/2024 and the Immediate Jeopardy was removed 04/05/2024. State Agency Validation: On 04/05/24, the SA validated through staff interviews, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): Resident #2 The SA verified through staff interview and record review, on 04/04/2024 at approximately 8:30 AM, the Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication. The SA verified through record review, sign-in sheets, and in-service reviews on 04/04/2024 at approximately 11:25 AM, the Administrator held a one-to-one in-service with admission Coordinator on the appointment scheduling process to include communication, scheduling and following up on appointments. The SA verified through record review on 04/04/2024 at approximately 12:30 PM, the admission Coordinator conducted an audit of current dialysis patients to review for appointments by contacting the dialysis center and verifying any outside appointment to ensure facility followed up correctly. There are currently twelve (12) dialysis patients. All appointments were followed up. The SA verified through record review on, 04/02/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. The SA verified through resident interview and sign in sheets, on 04/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility had Immediate Jeopardies. The SA verified through staff interview, sign-in sheets, and in-service reviews on 04/04/2024 at approximately 10:00 AM, the Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff will be allowed to return to work without completing. The SA verified through staff interview and sign-in sheet, on 04/04/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. The SA verified through staff interview and record review, on 04/04/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. The SA verified through staff interview, sign-in sheets, and in-service reviews on 04/04/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. On 04/05/24, the SA validated that all corrective actions had been taken by the facility to remove the IJ on 04/04/24 and the IJ was removed on 04/05/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review the facility failed to revise the care plan for a severely cognitively impaired resident who eloped from the facility for one (1) of nine (9) sampled residents. (Resident #1) The SA identified an Immediate Jeopardy (IJ) which began 3/31/24 when the facility allowed Resident #1 to exit the facility unsupervised and was found approximately eight-tenths of a mile from the facility by police. He was away from the facility for 81 minutes. The facility's failure to provide supervision resulted in elopement and places cognitively impaired residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. On 4/3/24 at 5:31 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and provided the IJ Template. The facility provided an acceptable Removal Plan on 4/4/24, in which the facility alleged all corrective actions were completed to remove the IJ on 4/4/24. The State Agency (SA) validated the Removal Plan on 4/5/24 and determined the IJ was removed on 4/5/24, prior to exit, and the scope and severity for 42 CFR 483.21 (b)(2) Care Plan Timing and Revision (F657) was lowered from a J to a D, while the facility monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Resident #1 Cross reference F 689 Review of facility policy titled Care Plans, Comprehensive Person-Centered, reviewed January 2023, revealed, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Care plans are revised as information about the residents and the residents' conditions change. Record review of Resident #1's Care Plan, with latest revision 11/02/23, revealed the resident likes to leave/sign out Leave of Absence (LOA) for personal outings. The Care Plan goal read, I will exhibit understanding and recognition of risk vs benefits while signed out LOA through next review date. A record review of the facility investigation revealed on 3/31/24 at approximately 8:30 PM, the Director of Nursing (DON) contacted the Administrator and stated the police had Resident #1 on (Formal Name of street in the community). The Administrator contacted the Interim DON, who was at the facility, to verify that Resident #1 was not in the facility. She confirmed that he was not. The facility driver was contacted and dispatched to pick up Resident #1 who remained under the supervision of the police officer until pick up. Resident #1 returned to the facility at 9:29 PM. Resident #1 was assessed by Interim DON with no injuries noted. An updated wander assessment was completed by the Administrator and Interim DON to reflect new behavior. The Administrator verified that the wander guard was working and placed the bracelet on the left wrist of Resident #1. Upon staff interviews and review of camera footage, the facility noted Resident #1 exiting the facility at 7:25 PM when an agency Licensed Practical Nurse (LPN) opened the door for him. When questioned by the Administrator, the LPN stated that she thought he was going to sit on the front porch. Resident #1 was admitted on [DATE] the facility with diagnoses including Epilepsy and Dependence on a wheelchair. In an interview with Licensed Practical Nurse #2 (LPN) at 8:35 AM on 4/3/24, she verified that in the past Resident #1 did go on Leave of Absence (LOA) outside the facility without supervision, but the facility staff no longer allowed him to go out unsupervised due to his confusion. LPN #2 was unsure when the facility stopped letting him go on leave of absence (LOA) by himself, but verified it was prior to 3/31/24. On 4/3/24 at 1:30 PM, during an interview with the Assistant Director of Nursing (ADON), she verified that Resident #1's most recent Brief Interview for Mental Status (BIMS) score on 2/22/24 was a five (5), indicating severe cognitive impairment and that he was not safe to go LOA by himself. During an interview with the Social Worker (SW) on 4/3/24 at 1:46 PM, she stated that once Resident #1's cognition declined, and his BIMS was less than 12 he was no longer safe to go LOA by himself . The SW verified that the resident's BIMS was five (5) on 2/22/24, indicating severe cognitive impairment. The SW verified Resident #1's care plan did not reflect that he could not go LOA by himself. She stated that based on Resident #1's care plan, staff could allow Resident #1 LOA by himself. She agreed that his care plan should have been updated to reflect that he was no longer safe to go LOA by himself when his BIMS score fell below 12 and verified that it was not updated until 4/1/24 after the resident left the building unsupervised. In an interview with Interim Director of Nursing (DON) on 4/4/24 at 9:45 AM, she agreed Resident #1's care plan should have been updated at the time he was determined to no longer be safe to go LOA unsupervised. Record review of the admission Record for Resident #1 revealed that the facility admitted the resident on 11/8/21 with a diagnosis of Epilepsy. Removal Plan On 3/31/2024 at approximately 9:35 PM the interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns. On 3/31/2024 at about 10:30 PM, the Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140. On 3/31/2024 at approximately 10:30 PM, staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status). On 3/31/2024 at approximately 1030 PM, the Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing. On 3/31/2024 at approximately 10:40 PM, Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator on 3/31/2024. On 3/31/2024 at approximately 10:40 PM, the wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist. On 3/31/2024, the facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility. On 3/31/24 at 10:45 PM, the Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility. On 3/31/2024 at approximately 11:05 PM, the Mississippi State Department of Health was notified of Resident #1 elopement. On 3/31/2024 at approximately 11:09 PM, the Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility. On 3/31/2024, licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. On 4/01/2024 approximately 12:30 AM, the LPN #1 initiated facility-based incident reporting on Resident #1. On 4/01/2024 approximately 10:00 AM, the Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected on 4/1/2024. On 4/1/2024 at approximately 10:30 AM, the Social Services Director updated the wander and elopement binders to ensure all are reflective of results. On 4/01/2024 at approximately 11:00 AM, the Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found. On 4/1/2024 at approximately 11:19 AM, the NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count. On 4/01/2024 at approximately 1:46 PM, the Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement. On 4/01/2024 at approximately 2:00 PM, Social Services completed a BIMS on Resident #1 which resulted in moderate cogitative impairment of a 9. On 4/1/2024 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/lnfection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. On 4/01/2024 at approximately 3:11 PM, Resident # 1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status. On 4/01/2024 at approximately 11 P.M., the Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement. On 4/2/2024 at about 11:30 PM, the Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift. On 4/2/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be in-se Nice on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. On 4/03/2024 at approximately 11:00 AM, NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start on 4/3/2024 at 9:00 PM. Starting 4/3/2024, a current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision. On 4/3/2024 at 5:50 PM., The final letter of investigation was sent to the Mississippi State Department of Health. On 4/3/2024 at 5:54 PM, the Attorney General was notified regarding the results of the Investigation. On 4/03/2024 at approximately 7:00 PM, the Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement. On 4/4/2024 at approximately 8:30 AM, the Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication. On 4/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility IJs. On 4/4/2024, an in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing. On 4/4/2024 at approximately 11:00 AM, the Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status). On 4/4/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. On 4/4/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. On 4/4/2024 at approximately 11:00 AM, An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision. On 4/4/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 4/04/2024 and the Immediate Jeopardy was removed. Validation: On 4/05/24, the SA validated through staff interviews, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record review, that interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns on 3/31/24 at 9:35 PM. Resident #1 had no negative skin issues or concern. The SA verified through record review, the Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140 on 3/31/24 at 10:30 PM. The SA verified through staff interview, sign-in sheets, and in-service reviews, on 3/31/2024 at approximately 10:30 PM, staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status). The SA verified through staff interview, sign-in sheets, and in-service reviews, on 3/31/2024 at approximately 10:30 PM the Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing. The SA verified through staff interview and record review, on 3/31/2024 at approximately 10:30 PM Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator on 3/31/2024. The SA verified through staff interview and record review, the wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist on 3/31/24 at 10:40 PM. The SA verified through staff interview and record review, on 3/31/24 at 10:45 PM, the facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility. The SA verified through staff interview, staff interview and record review, on 3/31/24 at 10:45 PM the Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility. The SA verified through staff interview and record review, on 3/31/24 at 11:05 PM the SA was notified of Resident #1 elopement. The SA verified through record review, on 3/31/2024 at approximately 11:09 PM, the Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility. The SA verified through staff interview and record review, on 3/31/2024, licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. The SA verified through record review, on 4/01/2024 approximately 12:30 AM, the LPN #1 initiated facility-based incident reporting on Resident #1. The SA verified through record review, on 4/01/2024 approximately 10:00 AM, the Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected on 4/1/24. The SA verified through staff interview and record review, on 4/1/2024 at approximately 10:30 AM, the Social Services Director updated the wander and elopement binders to ensure all are reflective of results. The SA validated through staff interview and record review that on 4/01/2024 at approximately 11:00 AM, the Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found. The SA verified through record review, on 4/1/2024 at approximately 11:19 AM, the NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count. The SA verified through staff interview, record review, and sign-in sheets, on 4/01/2024 at approximately 1:46 PM, the Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement. The SA verified through record review, on 4/01/2024 at approximately 2:00 PM, Social Services completed a BIMS on Resident #1 which resulted in moderate cogitative impairment of a 9. The SA verified through staff interview, sign-in sheets, and record review, on 4/1/2024 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/lnfection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. The SA verified through staff interview and record review, on 4/01/2024 at approximately 3:11 PM, Resident # 1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status. The SA verified through staff interview, and sign-in sheets, on 4/01/2024 at approximately 11 P.M., the Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement. The SA verified through staff interview and sign-in sheets, on 4/2/2024 at about 11:30 PM, the Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift. The SA verified through record review on 4/03/2024 at approximately 11:00 AM, NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start on 4/3/2024 at 9:00 PM. The SA verified through staff interview and record review, starting 4/3/2024, a current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision. The SA verified through record review, on 4/3/2024 at 5:50 PM, the final letter of investigation was sent to the SA. The SA verified through record review, on 4/3/2024 at 5:54 PM, the Attorney General was notified regarding the results of the investigation. The SA validated through interview and record, on 4/03/2024 at approximately 7:00 PM, the Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement. The SA verified through staff interview, sign-in sheets, and in-service reviews, on 4/4/2024, an in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing. The SA verified through record review on 4/4/2024 at approximately 11:00 AM, an audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision. The SA verified through staff interview, sign-in sheets, and in-service reviews and record review on 4/4/2024 at approximately 11:00 AM, the Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status). The SA verified through record review on, 4/2/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. The SA verified through resident interview and sign in sheets, on 4/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received IJs. The SA verified through staff interview, sign-in sheets, and in-service reviews on 4/04/2024 at approximately 10:00 AM, the Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff have been allowed to return to work without completing. The SA verified through staff interview and sign-in sheet, on 4/4/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. The SA verified through staff interview and record review, on 4/4/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. The SA verified through staff interview, sign-in sheets, and in-service reviews on 4/4/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. On 4/05/24, the SA validated that all corrective actions had been taken by the facility to remove the IJ on 4/04/24 and the IJ was removed on 4/05/24. Surveyor: [NAME], Shelbie

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review and facility policy review, the facility failed to provide supervision to prevent the elopement of a resident who was severely cognitively impaired for one (1) of five (5) residents reviewed. Resident #1. The facility failed to provide supervision to prevent the elopement of Resident #1, who was severely cognitively impaired and left the facility unattended. This failure allowed Resident #1 to be away from the facility unnoticed and unsupervised on 3/31/24 from 7:25 PM until 8:41 PM, when the facility was alerted that the resident was seen in the community, approximately eight-tenths (0.8) of a mile from the facility. This was approximately 81 minutes after Resident #1 was last observed in the facility. The facility's failure to provide supervision resulted in Resident #1's elopement and has the likelihood to result in serious harm, serious injury, serious impairment, or death for Resident #1 and all other cognitively impaired residents who leave the facility unsupervised. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 3/31/24 when a severely cognitively impaired resident left the facility unsupervised. The facility Administrator was notified of the IJ by the SA on 4/3/24 at 5:31 PM and provided the IJ Template. The facility provided an acceptable Removal Plan on 4/4/24, in which the facility alleged all corrective actions were completed to remove the IJ. The SA validated the Removal Plan and determined the IJ was removed on 4/5/24, prior to exit, and the scope and severity for 42 CFR(s) 483.25(d)(1)(2) Free of Accidents Hazard/supervision/devices (F689) was lowered from a J to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of a statement, on facility letterhead, dated 4/4/24, and signed by the Administrator, revealed that the facility does not have a policy related to resident leave of absence. Review of the facility's policy titled, Wanderer Management, Monitoring System & Resident Elopement Protocol revealed, Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . Record review of the Brief Interview for Mental Status (BIMS), dated 2/22/24 revealed Resident #1 had a score of five (5) indicating severe cognitive impairment. During an interview with Licensed Practical Nurse #2 (LPN) at 8:35 AM on 4/3/24, she stated that in the past Resident #1 did leave the building by himself, but they no longer let him do that due to his confusion. She could not remember when they stopped letting him go on leave of absence (LOA) by himself, but verified it was prior to 3/31/24. She stated she did not know how the facility communicated that a resident was not supposed to go LOA by themselves. In an interview with Resident #1 on 4/3/24 at 9:30 AM, he stated he remembered going outside on 3/31/24. He stated he just wanted to get some air. He denied having the exit code and stated he just went out the door. Resident #1 would not answer any further questions. In an interview with the Interim DON on 4/3/24 at 12:01 PM, she stated she arrived at the facility on 3/31/24 at 7:30 PM but did not see Resident #1 outside. She stated that around 8:30 PM the floor nurse asked her if she had seen Resident #1. She stated she went downstairs but the resident was not there. She stated that around 8:41 PM she received a call from the Administrator notifying her that the police had located the resident in the community. She stated that the resident was returned to the facility at 9:30 PM. She performed an assessment at that time and the resident had no injuries. She stated that the resident was wearing long jean pants, long sleeve pullover sweatshirt, tennis shoes and a cap. During a telephone interview with Police Officer #1 on 4/3/24 at 1:06 PM, he verified that on 3/31/24 he received a call from dispatch that a man in a wheelchair was seen in the middle of the street near (Proper Name of apartment complex). He said when he arrived the person was already gone. Officer #1 stated at that time he received a second call that a man in a wheelchair was seen at the intersection of (Proper Name of streets )where he located the resident. He stated the facility sent someone to pick the resident up. In an interview with the Administrator on 4/3/24 at 1:16 PM, she stated that she watched the surveillance camera footage for 3/31/24 and she saw that an agency nurse let Resident #1 outside at 7:25 PM. During an interview with LPN #1 on 4/3/24 at 1:24 PM, she verified that at 7:20 PM on 3/31/24 the resident was downstairs by the elevator, she asked him where he was going, and he stated nowhere so she went back upstairs. LPN # 1 stated around 8:30 PM she arrived at Resident #1's room, and he was not in the room. She notified the DON that she had not seen the resident since she was downstairs at 7:20 PM. She stated the DON went downstairs to look for the resident and at around 9:15 PM the DON told her that the resident had been found in the community by the police. During an interview with the Assistant Director of Nursing (ADON) on 4/3/24 at 1:30 PM, she verified that Resident #1's last BIMS score on 2/22/24 was a 5, indicating severe cognitive impairment and that he was not safe to go LOA by himself. She agreed that the facility did not have anything in place to ensure effective communication that the resident was not safe to go LOA by himself, but that they should have something in place. During an interview with the Social Worker (SW) on 4/3/24 at 1:46 PM, she stated that once Resident #1's cognition declined, and his BIMS was less than 12 he was no longer safe to go LOA by himself. She stated that residents must have a BIMS of 12 or higher to go LOA by themselves because of potential problems. She verified that Resident #1's BIMS on 2/22/24 was 5, indicating severe cognitive impairment and he was no longer safe to go outside the facility by himself. In an interview with Registered Nurse# 1 (RN) on 4/3/24 at 3:10 PM, she stated that due to Resident #1's increased confusion he was not safe to go LOA by himself. She stated that this information is communicated verbally during the report, and there is no written communication provided. In an interview with Certified Nursing Assistant (CNA) #1 on 4/3/24 at 3:15 PM, she stated that she does not know which residents can or cannot go LOA by themselves. During a telephone interview conducted with the Administrator on 4/3/24 at 3:27 PM, she stated she was notified Resident #1 was not in the facility on 3/31/24 at 8:30 PM, when the DON called informing her that he was seen by a witness in the community. She stated that she then contacted the facility and notified them of the resident's whereabouts and called the van driver to pick the resident up. During a telephone interview with the Van Driver on 4/3/24 at 3:46 PM, he verified the location in the community where he picked up Resident #1 on 3/31/24 at approximately 9:20 PM. During a telephone interview with LPN #3 on 4/5/24 at 11:00 AM, she verified on 3/31/24 Resident #1 was at the front door of the facility attempting to exit. She stated that she really did not know who the resident was. She stated that she thought he was just going to sit on the porch. LPN #3 stated that she was not aware that Resident #1 was not allowed to go out by himself. She stated there was no communication in place that informed her what residents could or could not leave the building unattended. Record review of Past Weather in (Name of City) dated 3/31/24 revealed that sunset was at 7:22 PM and it was 55 degrees Fahrenheit (F) from 7:30 PM to 9:30 PM with no precipitation. Record review of Google Maps revealed that the address where Resident #1 was located was eight-tenths (0.8) of a mile from the facility. Record review of the admission Record for Resident #1 revealed that the facility admitted the resident on 11/8/21 with diagnoses including Epilepsy. A record review of the facility investigation revealed Resident #1 was admitted on [DATE] the Facility with diagnoses including Epilepsy and Dependence on a wheelchair. On 3/31/24 at approximately 8:30 PM, Director of Nursing (DON) contacted the Administrator and stated the police had Resident #1 on (Formal Name of street in the community). The Administrator contacted the Interim DON ,who was at the facility, to verify that Resident #1 was not in the facility. She confirmed that he was not. The facility driver was contacted and dispatched to pick up Resident #1 who remained under the supervision of the police officer until pick up. Resident #1 returned to the facility at 9:29 PM. Resident #1 was given a head-to-toe assessment by Interim DON with no injuries noted. An updated wander assessment was completed by Administrator and Interim DON to reflect new behavior. The Administrator verified that the wander guard was working and placed the bracelet on the left wrist of Resident #1. Upon staff interviews and review of camera footage, Resident #1 noted exiting the facility at 7:25 PM when the agency Licensed Practical Nurse (LPN) opened the door for him. When questioned by the Administrator she stated that she thought he was going to sit on the front porch. The Administrator educated LPN on the fact that residents are required to sign out even if they are sitting on the porch. Resident #1 is his own responsible party. The Medical Director and Nurse Practitioner were also notified. Prior to this incident Resident #1 was not deemed a wander risk due to no previous exit seeking behavior and a previous wander assessment completed on 2/1/24 placed him at low risk for wandering. Resident #1's care plan was reviewed and updated by the interdisciplinary team to include new wander behaviors. The Wander Binder was updated to reveal new behavior. In services began on 3/31/24 on Abuse and Neglect, Resident's Rights, MS (Mississippi) Vulnerable Adult Act, and Elopement. A binder was started and placed at each nurse's station for Orientation Procedure. An Ad hoc Quality Assurance (QA) meeting was held on 4/1/2024 with the Medical Director, Interdisciplinary team to discuss events along with plan of correction. Social Services to follow up as needed for any physical, mental, or psychosocial needs. The labs obtained revealed the resident has a Urinary Tract Infection (UTI) and his treatment has been started. The resident remains his own Responsible Party but due to his variations in health status, and for process improvement the staff was in serviced to ensure BIMS (Brief Interview for Mental Status) verification is obtained along with the resident signing out prior to exit from facility. In conclusion, abuse and/or neglect by the facility could not be substantiated. Observation based on the reported sightings of the resident on 3/31/24 there were three (3) possible routes Resident #1 could have taken when he left the facility. On 4/3/24 at 6:00 PM, the SA retraced the possible routes that Resident #1 could have taken revealed that all routes were dimly lit with ditches and large culverts on the sides of the roads, as well as railroad tracks on all three (3) routes. All routes were eight-tenths (0.8) of a mile from the facility. Record review of the Incident Report from local police department revealed On 3-31-24, I (Proper Name of officer) was dispatched at 8:12 PM to look for a subject in front of (Proper Name of apartment complex) in a wheelchair in the middle of the roadway. I arrived on the scene at 8:16 PM. Upon my arrival, I did not see anyone in a wheelchair in the roadway. I rode around the apartment complex and still didn't see a subject in a wheelchair. I went back in service at 8:20 PM. I received another call at 8:27 PM about a male subject in the roadway on (Proper name of Street) near (Proper Name of street). I arrived on the scene at 8:28 PM. I came into contact with (Proper Name of Witness) she was following the male subject in her car so no one would run over him. We came to a stop near (Proper Name of Street). I came into contact with the male subject (Proper name of Resident #1) who was in a wheelchair. I asked if he was ok. He advised that he was ok and that he was just going home. There was a lady who lived next to where we were she called (Proper name of Facility) and talked to the director. I advised that I was calling Emergency Medical Services (EMS) to transport (Proper Name of Resident #1) back to the facility. The director advised that they were going to send a van to pick up (Proper Name of Resident #1). Record review of a facility Behavior Note dated 3/31/2024 at 9:30 PM, revealed This nurse got off the elevator to go get supplies at 7:20 PM on another unit. This nurse passed the resident sitting in wheelchair downstairs in hallway by the social worker's office door and asked, Where are you going? Resident answered, No where. This nurse said OK and proceeded to go get supplies on Annex unit. This nurse then went back up to her unit on the 2nd floor and started the med pass. When this nurse reached the resident room around 8:30 PM the resident was not in his room. DON was on the unit and this nurse asked if she had seen the resident. This nurse stated that the resident was downstairs earlier and is usually back in bed by now. DON (Formal Name of DON) stated that she would go look for the resident. DON returned at 9:15 PM and notified this nurse that the resident had left the building and was located near the police station. DON stated facility transportation was on the way to pick up the resident. Resident returned to unit per wheelchair around 9:30 PM with DON. Resident was assisted into bed and a head-to-toe assessment was performed by DON and this nurse. When asked why he left the building resident stated, I was going to my cousin house across the street to get my truck. Confusion noted. Resident received a wander guard for elopement monitoring to left wrist and placed on q (every) 15 minute checks for elopement risk while in bed. Administrator present in building. Facility Removal Plan On 3/31/2024 at approximately 9:35 PM the interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns. On 3/31/2024 at about 10:30 PM, the Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140. On 3/31/2024 at approximately 10:30 PM, staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status). On 3/31/2024 at approximately 1030 PM, the Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing. On 3/31/2024 at approximately 10:40 PM, Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator on 3/31/2024. On 3/31/2024 at approximately 10:40 PM, the wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist. On 3/31/2024, the facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility. On 3/31/24 at 10:45 PM, the Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility. On 3/31/2024 at approximately 11:05 PM, the Mississippi State Department of Health was notified of Resident #1 elopement. On 3/31/2024 at approximately 11:09 PM, the Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility. On 3/31/2024, licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. On 4/01/2024 approximately 12:30 AM, the LPN #1 initiated facility-based incident reporting on Resident #1. On 4/01/2024 approximately 10:00 AM, the Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected on 4/1/2024. On 4/1/2024 at approximately 10:30 AM, the Social Services Director updated the wander and elopement binders to ensure all are reflective of results. On 4/01/2024 at approximately 11:00 AM, the Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found. On 4/1/2024 at approximately 11:19 AM, the NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count. On 4/01/2024 at approximately 1:46 PM, the Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement. On 4/01/2024 at approximately 2:00 PM, Social Services completed a BIMS on Resident #1 which resulted in moderate cogitative impairment of a 9. On 4/1/2024 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/lnfection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. On 4/01/2024 at approximately 3:11 PM, Resident # 1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status. On 4/01/2024 at approximately 11 P.M., the Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement. On 4/2/2024 at about 11:30 PM, the Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift. On 4/2/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be inserviced on facility's policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. On 4/03/2024 at approximately 11:00 AM, NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start on 4/3/2024 at 9:00 PM. Starting 4/3/2024, a current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision. On 4/3/2024 at 5:50 PM., The final letter of investigation was sent to the Mississippi State Department of Health. On 4/3/2024 at 5:54 PM, the Attorney General was notified regarding the results of the Investigation. On 4/03/2024 at approximately 7:00 PM, the Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement. On 4/4/2024 at approximately 8:30 AM, the Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication. On 4/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received Immediate Jeopardies. On 4/4/2024, an in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing. On 4/4/2024 at approximately 11:00 AM, the Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status). On 4/4/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. On 4/4/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. On 4/4/2024 at approximately 11:00 AM, An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision. On 4/4/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 4/04/2024 and the Immediate Jeopardy was removed 4/05/2024. Validation: On 4/05/24, the SA validated through staff interviews, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): Resident # 1 The SA verified through record review, that interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns on 3/31/24 at 9:35 PM. Resident #1 had no negative skin issues or concern. The SA verified through record review, the Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140 on 3/31/24 at 10:30 PM. The SA verified through staff interview, sign-in sheets, and in-service reviews, on 3/31/2024 at approximately 10:30 PM, staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status). The SA verified through staff interview, sign-in sheets, and in-service reviews, on 3/31/2024 at approximately 10:30 PM the Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. No staff have been allowed to return to work without completing. The SA verified through staff interview and record review, on 3/31/2024 Resident #1's wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator on 3/31/2024. The SA verified through staff interview and record review, the wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist. The SA verified through staff interview, staff interview and record review, on 3/31/24 at 10:45 PM the Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility. The SA verified through staff interview and record review, on 3/31/24 at 11:05 PM the SA was notified of Resident #1 elopement. The SA verified through record review, on 3/31/2024 at approximately 11:09 PM, the Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility. The SA verified through staff interview and record review, on 3/31/2024, licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs. The SA verified through record review, on 4/01/2024 approximately 12:30 AM, the LPN #1 initiated facility-based incident reporting on Resident #1. The SA verified through record review, on 4/01/2024 approximately 10:00 AM, the Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected on 4/1/24. The SA verified through staff interview and record review, on 4/1/2024 at approximately 10:30 AM, the Social Services Director updated the wander and elopement binders to ensure all are reflective of results. The SA validated through staff interview and record review that on 4/01/2024 at approximately 11:00 AM, the Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found. The SA verified through record review, on 4/1/2024 at approximately 11:19 AM, the NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count. The SA verified through staff interview, record review, and sign-in sheets, on 4/01/2024 at approximately 1:46 PM, the Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement. The SA verified through record review, on 4/01/2024 at approximately 2:00 PM, Social Services completed a BIMS on Resident #1 which resulted in moderate cogitative impairment of a 9. The SA verified through staff interview, sign-in sheets, and record review, on 4/1/2024 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/lnfection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction. The SA verified through staff interview and record review, on 4/01/2024 at approximately 3:11 PM, Resident # 1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status. The SA verified through staff interview, and sign-in sheets, on 4/01/2024 at approximately 11 P.M., the Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement. The SA verified through staff interview and sign-in sheets, on 4/2/2024 at about 11:30 PM, the Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift. The SA verified through record review on 4/03/2024 at approximately 11:00 AM, NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start on 4/3/2024 at 9:00 PM. The SA verified through staff interview and record review, starting 4/3/2024, a current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision. The SA verified through record review, on 4/3/2024 at 5:50 PM, the final letter of investigation was sent to the SA. The SA verified through record review, on 4/3/2024 at 5:54 PM, the Attorney General was notified regarding the results of the investigation. The SA validated through interview and record, on 4/03/2024 at approximately 7:00 PM, the Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement. The SA verified through staff interview, sign-in sheets, and in-service reviews, on 4/4/2024, an in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing. The SA verified through record review on 4/4/2024 at approximately 11:00 AM, an audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision. The SA verified through staff interview, sign-in sheets, and in-service reviews and record review on 4/4/2024 at approximately 11:00 AM, the Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status). The SA verified through record review on, 4/2/2024 at approximately 3:30 PM, the Administrator Assistant developed an orientation binder for all agency' staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines. The SA verified through resident interview and sign in sheets, on 4/04/2024 at approximately 9:30 AM, Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility received IJs. The SA verified through staff interview, sign-in sheets, and in-service reviews on 4/04/2024 at approximately 10:00 AM, the Staff Development initiated in-servicing with all licensed nurses, transportation, front desk receptionist on communication with appointments to include the process with signing resident in and out of facility, the daily transportation log along with the sign out binder. Inservice also includes adding a step to the appointment communication process with admission Coordinator to review the communication tab within the electronic records to ensure all appointments are listed. No staff will be allowed to return to work without completing. The SA verified through staff interview and sign-in sheet, on 4/4/2024 at 12:44 PM, Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments. The SA verified through staff interview and record review, on 4/4/2024 at approximately 2:00 PM, Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans. The SA verified through staff interview, sign-in sheets, and in-service reviews on 4/4/2024, the Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, staff schedule and facility policy review the facility: 1) failed to protect the residents right to be free from neglect as evidenced by failure to ensure nursing staff provided supervision and nursing services to 25 residents of 146 residents who resided in the facility when a nurse failed to report for duty for the 11:00 PM to 7:00 AM shift on 1/27/24, which resulted in 14 residents not receiving medications. (Resident #1, Resident # 2, Resident # 3, Resident # 4 Resident #5, Resident # 6, Resident # 7, Resident # 8, Resident #9, Resident #10, Resident # 11, Resident # 12, Resident # 13, and Resident #15), four residents with significant medication errors (Resident #1, Resident # 2, Resident # 3, Resident # 5) and 2) failed to ensure a resident was free from verbal abuse when a Certified Nurse Assistant (CNA) cursed a resident for one (1) of eight (8) residents reviewed for abuse, Resident #27. The facility's failure to ensure sufficient licensed staff on 1/27/24-1/28/24 from 11:00 PM through 7:00 AM to administer medications, provide monitoring and supervision resulted in the deprivation of goods and services by staff of services necessary to attain or maintain physical, mental, and psychosocial well-being, and had the likelihood to cause residents residing on the Annex A hall unit of the facility serious injury, serious harm, serious impairment, or possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/02/24, which began on 1/27/24, when the facility's failure to ensure a licensed nurse was present to provide necessary nursing services. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Templates. The facility submitted an acceptable Removal Plan on 2/02/24 at 9:52 pm, in which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/02/24 and the IJ was removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ and SQC was removed on 2/03/24, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1) Abuse and Neglect (F 600), was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. CROSS REFERENCE F725, F760 Findings include: Review of the facility policy titled, Abuse Prohibition Policy, revised 11/7/23, revealed: Intent: .Each resident has a right to be free from abuse, mistreatment, neglect, .Policy: The facility will prohibit neglect, mental or physical abuse .of resident .Neglect - failure of the facility, it's employees or service providers to provide goods and services to the resident, necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident . Review of the facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed 3/2023, revealed: Policy Statement: Our facility provides nursing and related care and services for all residents .Factors considered in determining appropriate staffing ratios .include an evaluation of the diseases, conditions, physical and cognitive limitations of the resident population, and acuity. Minimum staffing requirements imposed by the state .are not necessarily considered a determination of sufficient and competent staffing. An interview with Licensed Practical Nurse (LPN) #1 on 2/1/24 at 10:50 AM, she revealed on 1/27/24, she notified the Staff Development Coordinator (SDC), that her relief did not show up at for the 7:00 PM-7:00 AM shift and the SDC stated she would notify the Director of Nursing (DON) and the Administrator and call around to find coverage. She stated that the SDC asked her if she would stay and administer the 9:00 PM medications. LPN #1 confirmed she worked until 11:00 PM when LPN #2 came over to count the Annex A medication cart, revealing she counted the cart and left the facility. LPN #1 then revealed when she returned to work on 1/28/24 at 7:00 AM, there was not a nurse assigned to the Annex A medication cart and she noticed the 6:00 AM medications had not been signed off as administered. She stated, I was told by one of the other nurses, not sure which one, that all the administrative nurses were aware that none of the 6:00 AM medications had been administered. LPN #1 then confirmed, potential concerns of there being no nurse to staff the Annex A Hall is the residents missed their medications, is the residents plan of care was not followed and that placed residents at risk to have adverse consequences such as Hypo-Hyperglycemia, unrelieved pain, seizures, and potential changes in their status that may not be identified. LPN #1 also revealed the facility consists of the 100 A and B Hall, 200 A and B Hall, and the Annex A and B Hall with each area having two medication carts and a nurse is supposed to be scheduled for each hall. During a phone interview with LPN #2 on 1/31/24 at 1:00 PM, she confirmed she counted the medication cart with LPN #1 on 1/27/24 at 11:00 PM so LPN #1 could go home. She revealed she was assigned to the 100 Hall and only counted the narcotics for the Annex A cart until someone came in. She confirmed she did not administer the 6:00 AM medications or monitor the residents on Annex A hall because she was assigned to the 100 Hall and was unable to take care of residents and administer medications for two halls. LPN #2 then confirmed she did not notify anyone that there was not a nurse for the Annex A cart or that the 6:00 AM medications were not administered because she thought LPN #1 informed all the administrative staff before she left at 11:00 PM. During a phone interview with LPN #3 on 1/31/24 at 2:30 PM, confirmed she worked on 1/27/24 from 7:00 PM-7:00 AM but she was unaware that the Annex A cart did not have a nurse assigned to it stating, I saw LPN #1 count the medication cart with another nurse. LPN # 3 then revealed she is an Agency nurse and does not know the staff very well and confirmed she did not monitor any residents on the Annex A hall and did not know they did not get their morning medications. An interview with the Assistant Director of Nursing (ADON) on 2/1/24 at 4:00 PM, he stated that the Registered Nurses (RN) take a call rotation and come in and work the medication cart if someone called in and coverage could not be found. An interview with the Administrator on 2/2/24 at 10:00 AM, she stated that she was not aware until around 6:45 AM on 1/28/24, that there was no nurse for Annex Hall Cart A from 11:00 PM until 7:00 AM on 1/27/24, and that the residents did not receive their 6:00 AM medications for 1/28/24. She then revealed that the SDC was the nurse on call for 1/27/24. She stated that the residents on Annex A hall were assessed by the RN supervisors on 1/28/24. She then stated she did not identify that the omission of some of the medications constituted significant medication errors. An interview with the ADON on 2/2/24 at 10:05 AM, he revealed that he was not aware that there was no nurse for Annex Hall Cart A from 11:00 PM until 7:00 AM on 1/27/24, and that the residents did not receive their 6:00 AM medications. He then stated he did not identify that the omission of insulin, anticonvulsants, blood thinners, and scheduled pain medications constituted as significant medication errors. The ADON stated that failure to administer insulin, anticonvulsants, blood thinners and scheduled pain medications could lead to hyperglycemia, seizures, and unrelieved pain. An interview on 2/2/24 at 10:20 AM, with the SDC, she stated that on 1/27/24 at 7:49 PM she received a text from LPN #1 notifying her that the night nurse had called in. The SDC stated she texted the Administrator, DON, and ADON at 7:55 PM. She then stated that initially she only received a response from the Administrator who told her that she would post the opening on the agency site and list it as premium. The SDC stated that premium means that it was a priority, and they were offering more pay for the shift to be covered. She stated that she then sent a text out to nurses to attempt to get the shift covered, but no one was available, so she notified the Administrator, DON, and ADON. She stated that DON responded and asked her to have LPN #1 administer the 9:00 PM medications. The SDC stated that no one accepted the shift from the agency website. She confirmed she never received a response from the ADON. During a further interview with the SDC she verified that she was the RN on call for 1/27/24, but that she is on light duty and cannot push a medication cart. She stated that she was only on call as a supervisor to attempt to find coverage for call ins. SDC further stated that she did not ask LPN #2 to count the cart with LPN #1 and she found out at 8:15 AM on 1/28/24 that the residents on the Annex A cart did not receive their 6:00 AM medications. In an interview with the RN Charge Nurse #1 on 2/2/24 at 10:30 AM, she stated she was notified by the SDC at 9:10 AM on 1/28/24 that there had been no nurse coverage for the Annex A residents for the 11:00 PM-7:00 AM shift and that the residents had not received 6:00 AM medications or accu-checks and to notify the provider and responsible party, assess the residents, and obtain vital signs. A phone interview with the DON on 2/2/24 at 10:45 AM, she stated that she received a phone call at 8:00 PM on 1/27/24 from the Respiratory Therapist (RT) #1 notifying her that the 7:00 PM to 7:00 AM nurse for the Annex A cart had called in. She stated that at that time she noticed that she had received a text at 7:58 PM from the SDC notifying her of the same thing. The DON stated that she asked the SDC if she had reached out to all the nurses that normally worked and the SDC told her that she had but no one could pick up the shift. She stated the SDC also informed her that LPN #1 had given the 9:00 PM medications for those residents. The DON then stated that she had fallen asleep and last talked to the SDC at 10:00 PM. The DON further stated that at 10:55 PM she reached out to the SDC asking what the plan for that cart was. She stated that the SDC told her that no one had responded to the shift posted on the agency website and that LPN #1 had left. The DON stated she reached back out to the SDC at 1:27 AM but there was still no nurse. The DON stated that at some point the ADON had informed her that he was out town and could not cover the shift. The DON stated that the agency nurse who was working the other cart on the Annex Hall told her that she had come to the desk and made rounds on the residents but did not administer the 6:00 AM medications. The DON stated that usually if there is no nurse for a certain cart then the nurses who are on duty will administer the medications. The DON stated that when she found out the residents had not received their medications, she informed the SDC to instruct the RN supervisor to assess the residents, notify the nurse practitioner and the resident representative. The DON stated that she knew the SDC was the nurse on call and if the on-call nurse cannot find coverage then they are to come in and work the cart. The DON stated that she was aware of the SDCs medical restrictions but did not think about the SDCs limitations when she received the call. A record review of the Daily Staffing Sheet revealed that there were five (5) nurses working from 11:00 PM to 7:00 AM on 1/27/24 with only one nurse assigned on the Annex Hall. A record review of the staff timecards for 1/27/24 through 1/28/24 revealed that there were five (5) Nurses working from 11:00 PM to 7:00 AM on 1/27/24. Resident #1 Review of the physician order for Resident # 1 revealed an order dated 10/12/23 for Apixaban Oral Tablet 5 mg (milligram) give one tablet via peg-tube (percutaneous endoscopic gastrostomy) two times daily related to Cerebral Infarction. Review of the January 2024 Medication Administration Record for Resident #1 revealed Apixaban Oral Tablet 5 mg (milligram) give one tablet via peg-tube two times daily at 6:00 AM and 2:00 PM, not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #1 to the facility on [DATE] with a diagnosis of Respiratory Failure, Hemiplegia, and Cerebral Infarction. Resident #2 Review of the physician's order for Resident # 2, revealed an order dated 5/19/23 for Novolin R (regular) injection solution 100 unit/ml (milliliter) (Insulin Regular Human): Inject as per sliding scale: if 60-80= OJ (orange juice) if semiconscious give some instant glucose. If unconscious give D5W (dextrose 5% in water)/AMP (ampule) IV or glucagon 1(one) mg IM/SQ (intramuscularly/subcutaneous). 81-200=0 units; 201-250=2 units; 251-300= 4 units; 301-350=6 units; 351-400 = 8 units; 400 + higher =10 units. Notify MD (medical doctor) for BS (blood sugar) (less than) < 60 & (greater than) > 401, subcutaneously before meals and bedtime. Review of a physician's order for Resident #2 dated 6/06/23 revealed Levothyroxine Sodium oral tablet 88 mcg (micrograms): give one tablet by mouth one time daily related to Hypothyroidism. Review of the January 2024 Medication Administration Record for Resident #2 revealed the blood glucose testing was not done to determine the need for the Novolin R: injection solution 100 unit/ml: Inject as per sliding scale before meals and bedtime scheduled at 6:00 AM and Levothyroxine Sodium oral tablet 88 mcg give one tablet by mouth one time daily at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #2 to the facility on 5/06/19 with a diagnosis Diabetes Mellitus (DM). Resident # 3 Record review of a physician orders for Resident # 3 revealed an order dated 6/25/20 for Hydroxychloroquine Sulfate Tablet 200 mg: Give one tablet by mouth two times daily .Lacosamide tablet 100 mg: give one tablet by mouth two times daily related to seizures .Keppra tablet 500 mg: give one tablet by mouth two times daily related to seizures .Celecoxib Capsule 200 mg: give one capsule by mouth two times daily related to Rheumatoid Arthritis. Record review of a physician orders for Resident # 3 revealed an order dated 7/30/20 for Gabapentin capsule 100 mg: give one capsule by mouth three times daily related to seizures .Pantoprazole Sodium tablet delayed release: give one tablet by mouth two times daily for indigestion related to Gastro-Esophageal Reflux Disease (GERD). Record review of the January 2024 Medication Administration Record for Resident #3 revealed Hydroxychloroquine Sulfate Tablet 200 mg at 6:00 AM Lacosamide tablet 100 mg at 6:00 AM Keppra tablet 500 mg: give one tablet by mouth two times daily at 6:00 AM, Celecoxib Capsule 200 mg 6:00 AM, Gabapentin capsule 100 mg 6:00 AM, and Pantoprazole Sodium at 6:00 AM, to not be signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #3 to the facility on 6/26/20 with diagnoses of Epilepsy, Rheumatoid Arthritis, and Gastro-Esophageal Reflux Disease. Resident #4 Record review of a physician orders for Resident # 3 revealed orders dated 7/13/23, revealed Norco Oral tablet 7.5-325 mg (Hydrocodone Acetaminophen): give one tablet enterally every eight hours related to pain; and an order dated 9/22/23, revealed Nexium oral packet 20 mg: give one packet via G-Tube (gastrostomy tube) one time a day related to Gastro-Esophageal Reflux Disease. Record review of the January 2024 Medication Administratioon Record for Resident #4 revealed, Norco oral tablet 7.5-325 mg enterally every eight hours at 6:00 AM and Nexium Oral packet 20 mg at 6:30 AM, to not be signed as administered on 1/28/24 at 6:00 AM and 6:30 AM. Record review of the Face Sheet revealed that the facility admitted Resident #4 to the facility on 6/02/23 with diagnoses of Anxiety and Gastro-Esophageal Reflux Disease. Resident #5 Record review of a physician orders for Resident # 5 revealed an order dated 7/13/23, revealed, Multivitamin-Minerals tablet: give one tablet by mouth one time a day related to Vitamin D Deficiency, an order dated 6/14/23, revealed, Euthyrox (Levothyroxine)oral tablet 88 mcg (micrograms) give one tablet by mouth one time a day related to Hypothyroidism; an order dated 9/11/23, revealed, Insulin Glargine Solution 100 units/ml: inject 8 units subcutaneously in the morning related to Type 2 (two) Diabetes; and an order dated 1/23/24, revealed, Furosemide 40 mg tablet: take one tablet by mouth twice daily before meals related to Hypertensive Heart Disease. Record review of the January 2024 Medication Administration Record for Resident # 5 revealed, Multivitamin-Minerals at 6:00 AM, Euthyrox oral tablet 88 mcg (micrograms) at 6:00 AM, Insulin Glargine Solution 100 units/ml: inject 8 units subcutaneously in the morning at 6:00 AM, and Furosemide 40 mg tablet at 6:00 AM were not signed off as administered on 1/28/24. Record review of the admission Record revealed that the facility admitted Resident #5 to the facility on 6/17/22 with diagnoses of Type 2 (two) Diabetes, Hypertensive Heart Disease, and Vitamin Deficiency. Resident #6 Review of the physician order for Resident # 6 revealed an order dated 12/26/23 for Folic Acid oral tablet one mg: give one tablet via peg-tube in the morning related to Vitamin Deficiency; and an order dated 12/27/23 for Atorvastatin Calcium oral tablet 10 mg: give one tablet vis peg-tube in the morning related to Hyperlipidemia. Record review of the January 2024 Medication Administration Record for Resident #6, revealed Folic Acid oral tablet at 6:30 AM, Atorvastatin Calcium oral tablet 10 mg at 6:00 AM, were not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident # 6 to the facility on [DATE] with diagnoses of Persistent Vegetative State and Vitamin Deficiency. Resident #7 Record review of the physician's orders for Resident # 7 revealed an order with a start date of 10/8/20 revealed, Diazepam tablet 5 mg give one tablet by mouth three times a day related to anxiety disorder; an order dated 4/4/21 revealed, Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale: if 60-80= OJ (orange juice) if semiconscious give some instant glucose. If unconscious give D5W AMP IV or glucagon 1(one) mg IM/SQ . 81-200=0 units; 201-250=2 units; 251-300= 4 units; 301-350=6 units; 351-400 = 8 units; 400 + higher =10 units. Notify MD for BS < 60 & > 401, subcutaneously before meals and bedtime related to Type Two Diabetes Mellitus, Seroquel tablet 100 mg: give one tablet by mouth three times a day related to Schizophrenia; and an order dated 11/9/23, revealed, Systane Complete Ophthalmic solution: instill one drop in both eyes two times a day related to Type Two Diabetes Mellitus. Review of the January 2024 Medication Administration Record for Resident # 7, revealed Diazepam tablet 5 mg give one tablet by mouth three times a day at 6:00 AM, the blood glucose testing to determine if Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale: was needed was not conducted, Seroquel tablet 100 mg at 6:00 AM, Systane Complete Ophthalmic solution at 6:00 AM, were not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident # 7 to the facility on 7/11/19 with diagnoses of Type Two Diabetes Mellitus, Restlessness and Agitation, and Schizophrenia. Resident # 8 Record review of the physician's orders for Resident # 8 revealed an order dated 1/9/24 revealed, Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale: if 60-80= OJ (orange juice) if semiconscious give some instant glucose. If unconscious give D5W AMP IV or glucagon 1(one) mg IM/SQ . 81-200=0 units; 201-250=2 units; 251-300= 4 units; 301-350=6 units; 351-400 = 8 units; 400 + higher =10 units. Notify MD for BS < 60 & > 401, subcutaneously before meals and bedtime related to Type Two Diabetes Mellitus. Vitamin C tablet 1000 mg: give one tablet via peg-tube one time a day related to Vitamin Deficiency. Record review of the January 2024 Medication Administration Record for Resident # 8 revealed the blood glucose testing to determine if Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale was needed was not conducted, was not signed off as administered on 1/28/24 at 6:00 AM. Vitamin C tablet 1000 mg: give one tablet via peg-tube one time a day was not signed off as administered at 6:00 AM on 1/28/24. Record review of the admission Record revealed that the facility admitted Resident #8 to the facility on [DATE] with diagnoses of Type 2 (two) Diabetes, Urinary Tract Infection, and Vitamin deficiency. Record review of the quarterly MDS Section C with an ARD of 11/07/23, revealed that Resident #8 had a BIMS score of 3 which indicated that she was severely cognitively impaired. Resident # 9 Record review of the physician's orders for Resident # 9 revealed orders dated 4/14/21 for Protonix tablet delayed Release 40 mg: give one tablet by mouth one time a day related to Gastro-Esophageal Reflux Disease .Dantrolene Sodium Capsule 50 mg: give one capsule by mouth three times a day related to contracture .Baclofen tablet 20 mg: give one tablet by mouth three times a day related to contracture of muscle. Record review of the January 2024 Medication Administration Record for Resident # 9 revealed Protonix tablet delayed Release 40 mg at 6:00 AM, Dantrolene Sodium Capsule 50 mg: give one capsule by mouth three times a day at 6:00 AM, Baclofen tablet 20 mg at 6:00 AM, to not be signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident # 9 to the facility on [DATE] with diagnoses of Contracture of muscle, right upper arm, Muscle Spasms, and Gastro-Esophageal Reflux Disease. Resident #10 Record review of the physician's orders for Resident # 10 revealed orders dated 9/15/21 for Protonix tablet delayed Release 40 mg: give one tablet by mouth one time a day related to Gastrointestinal (GI) bleed. Record review of the January 2024 Medication Administration Record for Resident # 10 revealed Protonix tablet delayed Release 40 mg at 6:00 AM, not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #10 to the facility on 4/6/21 with a diagnosis of Gastrointestinal Hemorrhage. Resident #11 Record review of the physician's orders for Resident # 11 revealed orders dated 4/27/21 for Sucralfate tablet one gram: give one tablet via peg-tube four times a day for Gastro-Esophageal Reflux Disease. Record review of the January 2024 Medication Admministration Record for Resident # 11 revealed, Sucralfate tablet one gram at 6;30 AM, was not signed off as administered on 1/28/24 at 6:30 AM. Record review of the admission Record revealed that the facility admitted Resident #11 to the facility on 9/17/20 with diagnoses of Persistent Vegetative State and Gastro-Esophageal Reflux Disease. Resident #12 Record review of the physician's orders for Resident # 12 revealed orders dated 11/29/23 for Lansoprazole tablet delayed release disintegrating 30 mg: give one tablet via peg-tube one time a day for Gastro-Esophageal Reflux Disease. Record review of the January 2024 Medication Administration Record for Resident # 12 revealed, Lansoprazole tablet at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #12 to the facility on [DATE] with a diagnosis of Gastro-Esophageal Reflux Disease. Resident #13 Record review of the physician's orders for Resident # 13 revealed orders dated 12/5/23 for Protonix tablet delayed release 40 mg: give one time a day for Gastro-Esophageal Reflux Disease .Buspirone tablet 5 mg: give one tablet by three times a day related to anxiety disorder started 12/5/23 and revised 2/1/24. Record review of the January 2024 Medication Administration Record for Resident # 13 revealed, Protonix tablet delayed release 40 mg at 6:00 AM, Buspirone tablet 5 mg at 6:00 AM, were not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #13 to the facility on [DATE] with diagnoses of Gastro-Esophageal Reflux Disease and Anxiety. Resident #15 Record review of the physician's orders for Resident # 15 revealed orders dated 11/30/23 for Hydralazine 100 mg tablet: give one tablet by mouth three times a day for Hypertension; and an order dated 1/25/24 for Tylenol eight-hour Arthritis pain tablet extended release 650 mg: give 2 tablets by mouth two times a day related to Poly osteoarthritis. Record review of the January 2024 Medication record for Resident #15 revealed, Hydralazine 100 mg tablet at 6:00 AM, Tylenol eight-hour Arthritis pain tablet extended release 650 mg at 6:00 AM, were not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #15 to the facility on [DATE] with diagnoses of Poly osteoarthritis and Hypertension. REMOVAL PLAN The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: On 2/2/2024 at 12:20 P.M. State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this removal plan. Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00pm to 7:00 am on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6 am medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 am medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 am dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2[TRUNCATED]

Based on record review, staff interview, and facility policy review the facility failed to report to the State Survey Agency that there was no licensed nurse available for 25 residents of 146 residents residing in the facility on the 11:00 to 7:00 shift on 1/27/24. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 1/27/24 when a licensed nurse failed to report for duty and the facility failed to find a replacement. Fourteen residents did not receive their 6:00 AM medications on the 11 PM to 7:00 AM shift on 1/27/24, related to no licensed nurse assigned to the Annex A medication cart. Twenty-five residents did not receive monitoring or supervision. The facility's failure to report the negligent practice, placed the residents at risk, and in a situation which was likely to cause serious injury, serious harm, serious impairment, or death. On 2/2/24 at 12:20 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ Templates. The facility submitted a credible Removal Plan on 2/2/24, in which the facility alleged all corrective actions to remove the IJ were completed on 2/2/24 and the IJ removed as 2/3/24. The SA validated the Removal Plan on 2/3/24 and determined the IJ was removed prior to exit. Therefore, the scope and severity for CFR(s)483.12(c)(1) - Reporting of Alleged Violations (F609) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Cross Reference F600, F725, F760 Review of the facility policy titled, Abuse Prohibition Policy, revised 11/7/23, revealed: .Neglect - failure of the facility, it's employees or service providers to provide goods and services to the resident, necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident .Reporting, 2. The facility will report all allegations and substantiated occurrences of abuse, neglect, or misappropriation of resident property to the state agency and all other agencies as required by law . Interview on 2/2/24 at 10:20 AM, with the Staff Development Coordinator (SDC), she stated that on 1/27/24 at 7:49 PM, she received a text from Licensed Practical Nurse #1 (LPN) notifying her that the night nurse had called in. The SDC stated she texted the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) at 7:55 PM. She stated that she then sent a text out to nurses to attempt to get the shift covered, but no one was available, so she notified the Administrator, DON, and ADON. The SDC stated that no one accepted the shift from the agency website. She confirmed she never received a response from the ADON. She verified that she was the Registered Nurse (RN) on call for 1/27/24, but that she is on light duty and cannot push a medication cart. She stated that she was only on call as a supervisor to attempt to find coverage for call ins. SDC further stated she found out at 8:15 AM on 1/28/24 that the residents on the Annex A cart did not receive their 6:00 AM medications. Interview via telephone with the DON on 2/2/24 at 10:45 AM, she stated that she received a phone call at 8:00 PM on 1/27/24 from Respiratory Therapist #1 (RT) notifying her that the 7:00 PM to 7:00 AM nurse for the Annex A hall had called in. The DON stated that she asked the SDC if she had reached out to all the nurses that normally worked and the SDC told her that she had, but no one could pick up the shift. The DON further stated that at 10:55 PM she reached out to the SDC asking what the plan for that cart was. She stated that the SDC told her that no one had responded to the shift posted on the agency website and that LPN #1 had left. The DON stated she reached back out to the SCD around 1:27 AM but there was still no nurse. The DON stated that the agency nurse who was working the other cart on the Annex Hall told her that she had come to the desk and made rounds on the residents but did not administer the 6:00 AM medications. The DON stated that she knew the SDC was the nurse on call and if the on-call nurse cannot find coverage then they are to come in and work the cart. The DON stated that she was aware of the SDCs medical restrictions but did not think about the SDCs limitations when she received the call. The DON stated that when she found out the residents had not received their medications, she informed the SDC to instruct the Registered Nurse Supervisor (RNS) to assess the residents, notify the nurse practitioner and the responsible party. Interview with the Administrator on 2/2/24 at 10:00 AM, she stated that she was notified around 7:00 AM on 1/28/24 that there was no nurse for the Annex cart A and that some of the residents did not receive their medications scheduled for 6:00 AM. She stated that she did not report the incident to the State Agency. A record review of the Job Description: Facility Administrator, dated March 2017, revealed .Essential Functions and Responsibilities .Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal and other regulatory guidelines .Report incident reports to proper company and agency authorities in accordance with regulatory guidelines. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00pm to 7:00 am on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6 am medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 am medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 am dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, and staff interviews that on, in-services were initiated, and staff on duty has received the in-services. The SA validated on 2/3/24, that all corrective actions had been taken by the facility to remove the IJ during the survey on 2/2/24 and the IJ was removed on 2/3/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review, record review, facility policy review, and staff interview, the facility failed to implement a comprehensive care plan related to medication administration for 14 of 25 residents reviewed for care plans. The facility's failure to implement care plans, placed the residents at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. On 2/2/24, the State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 1/27/2024, with the facility's failure to provide a licensed nurse to implement comprehensive care plans resulted in 14 residents not receiving medications per physician's orders. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator (NHA) of the IJ and provided the Administrator with the IJ Templates. The facility submitted a credible Removal Plan on 2/2/24 at 9:52 PM, in which the facility alleged all corrective actions to remove the IJ were completed on 2/2/24 and the IJ removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ was removed prior to exit. Therefore, the scope and severity for CFR483.21(b)(1) - Develop/Implement Comprehensive Care Plan (F656) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of facility policy titled Care Plans, Comprehensive Person-Centered, reviewed January 2023, revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . An interview with Licensed Practical Nurse (LPN) #1 on 2/1/24 at 10:50 AM, she confirmed that concerns from there being no nurse to staff the Annex A Hall is the residents missed their medications, the residents plan of care was not followed and that placed residents at risk to have adverse consequences such as Hypo-Hyperglycemia, unrelieved pain, seizures, and potential changes in their status that may not be identified. An interview with the RN Charge Nurse #1 on 2/2/24 at 10:30 AM, she revealed resident's plan of care was not followed when their medications and accu-checks were missed, resulting in the need to assess the resident for possible adverse outcomes. Resident #1 A review a care plan for Resident # 1 titled, The resident is on anticoagulant therapy (Apixaban) r/t (related to), last revised 11/27/2023, revealed Interventions/Task: Administer Anticoagulant medications as ordered by the physician . Review of the January 2024 Medication Administration Record for Resident #1 revealed Apixaban Oral Tablet 5 mg (milligram) give one tablet via peg-tube (percutaneous gastrostomy) was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #1 to the facility on [DATE] with a diagnosis of Respiratory Failure, Hemiplegia, and Cerebral Infarction. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 1/11/24, revealed that Resident # 1 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated that he was severely cognitively impaired. Resident #2 A review of a care plan for Resident # 2 titled, The resident has a diagnosis of Diabetes Mellitus . Interventions: Administer medications as ordered by the physician . A review of the care plan for Resident # 2 titled, The resident has Hypothyroidism and is at risk for complications, revealed Interventions: Give thyroid replacement as ordered . Review of the January 2024 Medication record for Resident #2 revealed the blood glucose testing to determine if Novolin R: injection solution 100 unit/ml: Inject as per sliding scale before meals and bedtime scheduled at 6:00 AM, and Levothyroxine Sodium oral tablet 88 mcg (micrograms) give one tablet by mouth one time daily at 6:00 AM, was not signed off as conducted/administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #2 to the facility on 5/06/19 with a diagnosis Diabetes Mellitus (DM). Record review of the Quarterly MDS Section C with an Assessment Reference Date ARD of 11/16/23, revealed that Resident # 2 had a BIMS score of 6 which indicated that she was severely cognitively impaired. Resident #3 A review of a care plan for Resident# 3 titled, The resident has a seizure disorder, revealed, Interventions: Gabapentin Capsule 100 mg .Keppra .Lacosamide as ordered. A review of a care plan for Resident # 3 titled, The resident has Rheumatoid Arthritis, revealed, Interventions: Give analgesics as ordered. A review of a care plan for Resident # 3 titled, The resident has diagnosis of GERD, Interventions: Give medications as ordered. Review of the January 2024 Medication Administration Record for Resident #3 revealed Hydroxychloroquine Sulfate Tablet 200 mg, Lacosamide tablet 100 mg, Keppra tablet 500 mg, Celecoxib Capsule 200 mg, Gabapentin capsule 100 mg, and Pantoprazole Sodium tablet was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #3 to the facility on 6/26/20 with diagnoses of Epilepsy, Rheumatoid Arthritis, and Gastro-Esophageal Reflux Disease. Record review of the Quarterly MDS Section C with an ARD of 12/15/23, revealed that Resident # 3 had a Brief Interview of BIMS score of 15 which indicated that he was cognitively intact. Resident #4 A review of a care plan for Resident #4 titled, The resident is at risk for pain related to Joint pain, Chronic Respiratory Failure, left sided Hemiplegia, Diabetes Mellitus, revealed, Interventions: Give analgesics as ordered. A review of a care plan for Resident # 4 titled, The resident has diagnosis of GERD, revealed, Interventions: Give medications as ordered. Review of the January 2024 Medication Administration Record for Resident #4 revealed, Norco oral tablet 7.5-325 mg, Nexium Oral packet 20 mg was not signed as administered on 1/28/24 at 6:00 AM and 6:30 AM. Record review of the admission Record revealed that the facility admitted Resident #4 to the facility on 6/02/23 with diagnoses of Anxiety and Gastro-Esophageal Reflux Disease. Record review of the Quarterly MDS Section C with an ARD of 12/18/23, revealed that Resident # 4 had a BIMS score of 12 which indicated that she was moderately cognitively impaired. Resident #5 A review of a care plan for Resident #5 titled, The resident has a diagnosis of HTN (hypertension) with Heart failure . Interventions: Give cardiac medications as ordered . A review of a care plan for Resident # 5 titled, The resident has diagnosis of Diabetes Mellitus .Interventions: Diabetic medications as ordered by doctor . A review of a care plan for Resident # 5 titled, The resident has Hypothyroidism . Interventions: Euthyrox as ordered . A review of a care plan for Resident # 5 titled, The resident is at risk for nutritional problems related to vitamin deficiency, DM, morbid obesity, protein calorie malnutrition, history of wanting to lose weight . Interventions: Administer medications as ordered . Review of the January 2024 Medication Administration Record for Resident # 5 revealed, Multivitamin-Minerals, Euthyrox oral tablet 88 mcg (micrograms), Insulin Glargine Solution 100 units/ml: inject 8 units, Furosemide 40 mg tablet was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #5 to the facility on 6/17/22 with diagnoses of Type 2 (two) Diabetes, Hypertensive Heart Disease, and Vitamin Deficiency. Record review of the MDS Section C with an ARD of 11/27/23, revealed that Resident # 5 had a BIMS score of 15 which indicated that she was cognitively intact. Resident #6 A review of a care plan for Resident # 6 titled, The resident has the potential nutritional problem related to Vitamin Deficiency .Administer medications as ordered . A review of a care plan for Resident # 6 titled, The resident has impaired circulation .Interventions: Administer statin medication .' Review of the January 2024 Medication Administration Record for Resident #6, revealed, Folic Acid oral tablet give one tablet via peg-tube two times daily at 6:30 AM and Atorvastatin Calcium oral tablet 10 mg was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident # 6 to the facility on [DATE] with diagnoses of Persistent Vegetative State and Vitamin Deficiency. Resident #7 A review of a care plan for Resident # 7 titled, The resident uses psychotropic medications Seroquel related to schizoaffective disorder, revealed Interventions: Administer psychotropic (Seroquel) as ordered by physician. A review of a care plan for Resident # 7 titled, The resident uses anti-anxiety medications Ativan and Diazepam related to anxiety disorder, revealed Intervention: Administer medications as ordered by physician. A review of a care plan for Resident # 7 titled, The resident has diagnosis of Diabetes Mellitus revealed, Interventions: Diabetic medications as ordered by doctor. Review of the January 2024 Medication Administration Record for Resident # 7, revealed Diazepam tablet 5 mg at 6:00 AM , the blood glucose test to determine if Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale was needed was not conducted, Seroquel tablet 100 mg, and Systane Complete Ophthalmic solution was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident # 7 to the facility on 7/11/19 with diagnoses of Type Two Diabetes Mellitus, Restlessness and Agitation, and Schizophrenia. Record review of the Quarterly MDS Section C with an ARD of 11/27/23, revealed that Resident # 5 had a BIMS score of 10 which indicated that he was moderately cognitively impaired. Resident # 8 A review of a care plan for Resident # 8 titled, The resident has Vitamin Deficiency . Interventions: Give medications as ordered . A review of a care plan for Resident # 8 titled, The resident has diagnosis of Diabetes Mellitus, revealed, Interventions: Insulin Lispro Solution 100 unit/ml inject as per sliding scale as ordered. Review of the January 2024 Medication record for Resident # 8 revealed the blood glucose test to determine if Novolin R injection solution 100 unit/ml (Insulin Regular Human): Inject as per sliding scale, Vitamin C 1000 mg at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #8 to the facility on [DATE] with diagnoses of Type 2 (two) Diabetes, Urinary Tract Infection, and Vitamin deficiency. Record review of the quarterly MDS Section C with an ARD of 11/07/23, revealed that Resident #8 had a BIMS score of 3 which indicated that she was severely cognitively impaired. Resident # 9 A review of a care plan for Resident # 9 titled, The resident has chronic pain related to Cerebral Palsy, headaches and muscle spasms, contractures of right and left hand .Interventions: Give medications as per orders . A review of a care plan for Resident # 9 titled, The resident has GERD .Interventions: Give medications as ordered . Review of the January 2024 Medication Administration Record for Resident # 9 revealed, for Protonix tablet delayed Release 40 mg. Dantrolene Sodium Capsule 50 mg, and Baclofen tablet 20 mg was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident # 9 to the facility on [DATE] with diagnoses of Contracture of muscle, right upper arm, Muscle Spasms, and Gastro-Esophageal Reflux Disease. Record review of the MDS Section C with an ARD of 12/19/23, revealed that Resident #9 had a BIMS score of 9 which indicated that he was moderately cognitively impaired. Resident #10 A review of a care plan for Resident # 10 titled, The resident has alteration in hematological status related to history of GI bleed . Interventions: Give medications as ordered . Review of the January 2024 Medication Administration Record for Resident # 10 revealed, for Protonix tablet delayed Release 40 mg was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the Face Sheet revealed that the facility admitted Resident #10 to the facility on 4/6/21 with a diagnosis of Gastrointestinal Hemorrhage. Record review of the MDS Section C with an ARD of 11/29/23, revealed that Resident #10 had a BIMS score of 15 which indicated that she was cognitively intact. Resident #11 A review of a care plan for Resident # 11 titled, The resident has GERD (Gastro-Esophageal Reflux Disease) .Interventions: Sucralfate as ordered . Review of the January 2024 Medication Administration Record for Resident # 11 revealed, Sucralfate tablet one gram: give one tablet via peg-tube four times a day at 6;30 AM was not signed off as administered on 1/28/24 at 6:30 AM. Record review of the admission Record revealed that the facility admitted Resident #11 to the facility on 9/17/20 with diagnoses of Persistent Vegetative State and GERD. Resident #12 A review of a care plan for Resident # 12 titled, The resident has GERD .Interventions: Lansoprazole as ordered . Review of the January 2024 Medication Administration Record for Resident # 12 revealed, Lansoprazole tablet at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #12 to the facility on [DATE] with a diagnosis of Gastro-Esophageal Reflux Disease. Record review of the MDS Section C with an ARD of 12/20/23, revealed that Resident #12 had a Staff Assessment for Mental Status coded as severely cognitively impaired. Resident #13 A review of a care plan for Resident # 13 titled, The resident has potential nutritional problem related GERD . Interventions: Administer medications as ordered . A review of a care plan for Resident # 13 titled, The resident uses anti-anxiety medications (Buspar) related to anxiety disorder .Interventions: Administer Anti-Anxiety medications as ordered . Review of the January 2024 Medication Administration Record for Resident # 13 revealed, Protonix tablet at 6:00 AM .Buspirone tablet 5 mg at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #13 to the facility on [DATE] with diagnoses of Gastro-Esophageal Reflux Disease and Anxiety. Record review of the MDS Section C with an ARD of 12/15/23, revealed that Resident #13 had a BIMS score of 14 which indicated that she was cognitively intact. Resident #15 A review of a care plan for Resident # 15 titled, The resident has a diagnosis of Hypertension .Interventions: Administer medications as ordered . A review of a care plan for Resident # 15 titled, The resident is at risk for pain related to GOUT End stage Renal Disease, DM . Interventions: Administer analgesics as ordered . Review of the January 2024 Medication Administration Record for Resident #15 revealed, Hydralazine 100 mg tablet at 6:00 AM, Tylenol eight-hour Arthritis pain tablet extended release 650 mg at 6:00 AM, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #15 to the facility on [DATE] with diagnoses of Poly osteoarthritis and Hypertension. Record review of the MDS Section C with an ARD of 12/14/23, revealed that Resident #15 had a BIMS score of 11 which indicated that she was moderately cognitively impaired. REMOVAL PLAN The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. Validation On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, resident and staff interviews, the facility failed to provide: 1. sufficient qualified nursing staff to provide nursing related services to assure resident safety, as evidenced by failure to ensure a licensed nurse was present to administer medications, and monitoring for 25 of 52 residents on the Annex Hall from 11:35 PM on 1/27/24 to 7:00 AM on 1/28/24. and 2. failed to ensure sufficient staff to provide care and services for two (2) of 22 residents reviewed. The Licensed Practical Nurse (LPN) who was scheduled to report at 7:00 PM on 1/27/24 did not arrive for her shift at the facility. Licensed Practical Nurse (LPN) #1 had worked since 7:00 AM and left the facility at 11:35 PM without on-site licensed nurse relief present. At this time, LPN # 2 counted the narcotics on the medication cart for Annex A hall and took the keys to the cart but did not accept responsibility for the twenty (25) residents on the Annex A hall of the facility. The Administrator, Director of Nursing (DON), and Staff Development Coordinator (SDC) were aware that the scheduled LPN did not show up for her shift. Staff and agency nurses did not respond to the call for replacement. No licensed nurse reported to duty on the Annex A hall of the facility between 11:35 PM and 7:00 AM. The facility failed to follow its stated practice for replacing staff in case of call-ins or no call, no shows. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staff Development Coordinator (SDC) were aware of the staffing problem. The On-Call SDC failed to report to duty related to limitations. The facility's failure to provide a licensed nurse to administer medications, and monitoring for 8 (eight) hours had the likelihood to cause all residents on Annex Cart A serious harm, serious injury, serious impairment, or possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) on 2/02/24, which began on 1/27/24, when the facility's failure to ensure sufficient licensed nurse was present to provide necessary nursing services. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Templates. The facility submitted an acceptable Removal Plan on 2/02/24 at 9:52 PM which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/02/24 and the IJ was removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ was removed on 2/03/24, prior to exit. Therefore, the scope and severity for 42 CFR 483.35(a) Sufficient Staffing was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Cross Reference F600, F690 and F760 Record review of the facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed 3/2023, revealed, Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans .Minimum staffing requirements imposed by the state .are not necessarily considered a determination of sufficient and competent staffing. A record review of the Daily Staffing Sheet revealed that there were five (5) nurses working from 11:00 PM to 7:00 AM on 1/27/24 with only one nurse assigned on the Annex Hall. A record review of the staff timecards for 1/27/24 through 1/28/24 revealed that there were five (5) Nurses working from 11:00 PM to 7:00 AM on 1/27/24. During an interview with Licensed Practical Nurse (LPN) #1 on 2/1/24 at 10:50 AM, she revealed on 1/27/24, she notified the Staff Development Coordinator (SDC), that she did not have relief for the 7:00 PM-7:00 AM shift because the scheduled nurse did not show up. The SDC stated she would notify the Director of Nursing (DON) and the Administrator and call around to find coverage. LPN #1 stated that the SDC asked her if she would stay and administer the 9:00 PM medications. LPN #1 confirmed she worked until 11:00 PM and then LPN #2 came over to count the Annex A medication cart. She stated she counted the cart with LPN #2 and left the facility. LPN #1 then revealed when she returned to work on 1/28/24 at 7:00 AM there was not a nurse assigned to the Annex A medication cart and she noticed the 6:00 AM medications had not been signed off as administered and stated I was told by one of the other nurses, not sure which one, that all the administrative nurses were aware that none of the 6:00 AM medications had been administered. LPN #1 stated that , potential concerns of there being no nurse to staff the Annex A Hall is the residents missed their medications, is the residents plan of care was not followed and that placed residents at risk to have adverse consequences such as Hypo-Hyperglycemia, unrelieved pain, seizures, and potential changes in their status that may not be identified. LPN #1 also revealed the facility consists of the 100 A and B Hall, 200 A and B Hall, and the Annex A Hall and Annex B Hall with each area having two medication carts and a nurse is supposed to be scheduled for each hall. A phone interview with LPN #2 on 1/31/24 at 1:00 PM, confirmed she counted the medication cart with LPN #1 on 1/27/24 at 11:00 PM. She stated she was assigned to the 100 Hall and only counted the narcotics for the Annex A cart until someone came in. LPN #2 confirmed she did not notify anyone that there was not a nurse for the Annex A cart. She stated she thought LPN #1 informed all the administrative staff before she left at 11:00 PM that there was no nurse for that cart. A telephone interview with LPN #3 on 1/31/24 at 2:30 PM, confirmed she worked the Annex B Hall on 1/27/24 from 7:00 PM-7:00 AM but she was unaware that the Annex A cart did not have a nurse assigned to it. She stated, I saw LPN #1 count the medication cart with another nurse. LPN # 3 then stated that she is an agency nurse and does not know the staff very well and confirmed she did not monitor any residents on the Annex A hall and did not know they did not get their morning medications. During an interview with the Assistant Director of Nursing (ADON) on 2/1/24 at 4:00 PM, he stated that the Registered Nurses (RN) take a call rotation and come in and work the medication cart if someone called in and coverage could not be found. During an interview with the Administrator on 2/2/24 at 10:00 AM, she stated that she was not aware that there was no nurse on the Annex A hall from 11:00 PM until 7:00 AM on 1/27/24 until around 7:00 AM on 1/28/24, and that the residents did not receive their 6:00 AM medications for 1/28/24. She then revealed that the SDC was the nurse on call for 1/27/24. During an interview with the ADON on 2/2/24 at 10:05 AM, he revealed that he was not aware that there was no nurse on the Annex Hall from 11:00 PM until 7:00 AM on 1/27/24, and that the residents did not receive their 6:00 AM medications. During an interview on 2/2/24 at 10:20 AM, with the SDC, she stated that on 1/27/24 at 7:49 PM she received a text from LPN #1 notifying her that the night nurse had called in. The SDC stated she texted the Administrator, DON, and ADON at 7:55 PM. The SDC stated that initially she only received a response from the Administrator who told her that she would post the opening on the agency site. She stated that she then sent a text out to nurses to attempt to get the shift covered, but no one was available, so she notified the Administrator, DON, and ADON. The SDC stated that no one accepted the shift from the agency website. She confirmed she never received a response from the ADON. During a further interview with the SDC she verified that she was the RN on call for 1/27/24, but that she is on light duty and cannot push a medication cart. She stated that she was only on call as a supervisor to attempt to find coverage for call ins. SDC further stated that she did not ask LPN #2 to count the cart with LPN #1 and she found out at 8:15 AM on 1/28/24 that the residents on the Annex A cart did not receive their 6:00 AM medications. During an interview with the RN Charge Nurse #1 on 2/2/24 at 10:30 AM, she stated she was notified by the SDC at 9:10 AM on 1/28/24 that there had been no nurse coverage for the Annex A residents for the 11:00 PM-7:00 AM shift and that the residents had not received 6:00 AM medications or accu-checks and to notify the provider and responsible party, assess the residents, and obtain vital signs. During a telephone interview with the DON on 2/2/24 at 10:45 AM, she stated that she received a phone call at 8:00 PM on 1/27/24 from Respiratory Therapist #1 (RT) notifying her that the 7:00 PM to 7:00 AM nurse for Annex A hall had called in. She stated that at that time she noticed that she had received a text at 7:58 PM from the SDC notifying her of the same thing. The DON stated that she asked the SDC if she had reached out to all the nurses that normally worked and the SDC told her that she had but no one could pick up the shift. The DON then stated that she had fallen asleep and last talked to the SDC at 10:00 PM. The DON further stated that at 10:55 PM she reached out to the SDC asking what the plan for that cart was. She stated that the SDC told her that no one had responded to the shift posted on the agency website and that LPN #1 had left. The DON stated that at 1:27 AM she reached back out to the SCD around but there was still no nurse. The DON stated that at some point the ADON had informed her that he was out town and could not cover the shift. The DON stated that the agency nurse who was working the other cart on the Annex Hall told her that she had come to the desk and made rounds on the residents but did not administer the 6:00 AM medications. The DON stated that usually if there is no nurse for a certain cart then the nurses who are on duty will administer the medications. The DON stated that when she found out the residents had not received their medications, she informed the SDC to instruct the RN supervisor to assess the residents, notify the nurse practitioner and the responsible party. The DON stated that she knew the SDC was the nurse on call and if the on-call nurse cannot find coverage then they are to come in and work the cart. The DON stated that she was aware of the SDCs medical restrictions but did not think about the SDCs limitations when she received the call. Resident #1 During an interview with Resident #1 on 1/31/24 at 9:30 AM, revealed they frequently must wait long periods of time for someone to provide incontinent care. Resident #1 stated It is worse on the night shift because they do not have enough staff. Resident #1 reported that he has sat in his bowel movement (BM) for an entire shift. During an interview with Anonymous Resident # 2 on 1/31/24 at 11:15 AM revealed the staff does not come in to check or change them at all on the night shift. During a phone interview with Anonymous Staff #1 on 1/31/24 at 5:45 PM, stated that there are not enough staff members to take care of the residents on the Annex and they are neglected. Staff #1 also stated that most of the residents are dependent, and it takes two staff members to care for them and some residents do not get changed all night. A phone interview with Anonymous Staff #2 on 1/31/24 at 7:14 PM, stated that the Annex does not have enough staff to take care of residents and the nurses do not help. They also stated that residents stay wet for extended periods of time. During an observation and interview on 2/1/24 at 12:35 AM, upon entering the Annex Hall observed two nurses sitting behind the Annex nursing desk. Two Certified Nurse assistants (CNAs) were standing in front of the desk and one CNA was walking towards the desk. An interview with Licensed Practical Nurse (LPN) #5 revealed she was working on the 11 PM to 7 AM assignment for the CNAs. She stated We were waiting for staff to arrive, we had four CNAs scheduled, one was a no call no show, the other did not arrive until 12:00 AM. An observation of Resident #1 with CNA #1 on 2/1/24 at 12:58 AM, revealed the room had a strong urine odor. Resident #1 was observed lying on his right side covered with a sheet and was observed to be wet with urine from the mid chest area to the bottom of the sheet. CNA #1 pulled back the top sheet from Resident #1 and the bottom sheet was soaked with urine extending down the bottom of the mattress and mid back area with a brown ring at edge of both sides of the bed. CNA #1 confirmed the resident was soaked and laying on sheets with old dried urine noted at the edges of the sheets. Record review of the admission Record revealed that the facility admitted Resident #1 to the facility on [DATE] with diagnoses that included Respiratory Failure, Hemiplegia, and Cerebral Infarction. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 1/11/24, revealed Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated that she was severely cognitively impaired. Section H revealed Resident #1 was always incontinent of bowel and bladder. Resident #8 On 2/1/24 at 12:45 AM, during an observation and interview of the Annex Hall , a voice was heard coming from room Resident #8's room. Resident #8 was saying what took you so long, I'm soaked, I'm soaked wet. An interview with CNA # 1 reported as he exited Resident #8's room that Resident #8 was upset because she was soaking wet. He verbalized he just got his assignment at 12:40 AM and had not made previous rounds, only answered call lights because he did not know which patients he would be assigned. He then stated, this happens all the time we rarely have enough help and the residents on this hall are bed bound total care residents requiring heavy physical assistance of more than one staff member. An observation of the incontinent brief that was removed from Resident #8 by CNA #1 during perineal care was observed to be extremely saturated with dark yellow urine with a strong urine odor. There was a large bulking noted to the absorbent layer to the diaper lining with saturation noted from the top of the front to the top of the back of the brief. CNA #1 confirmed the brief removed from Resident #8 was very saturated with urine and heavy. Record review of the admission Record revealed the facility admitted Resident #8 to the facility on [DATE] with diagnoses that included Type 2 (two) Diabetes and Vitamin deficiency. Record review of the Quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/07/23, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated that she was severely cognitively impaired. Section H with an ARD of 1/05/24 revealed she was always incontinent of bowel and bladder. In an interview with the Administrator on 2/2/24 at 10:20 AM, revealed on 1/31/24 on the 11 PM-7 PM shift the nurse should have made the assignment for the CNAs at the beginning of the shift to begin rounds and then adjust the assignments as the other staff came in. She confirmed if the sheets were wet then the resident had probably not been changed since previous shift. In an interview with the Assistant Director of Nursing (ADON) on 2/2/24 at 10:25 AM, he revealed concerns from not changing resident and leaving them wet is skin concerns such as moisture associated skin damage and urinary tract infections. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: On 2/2/2024 at 12:20 P.M. State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this removal plan. Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00pm to 7:00am on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6 am medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 am medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 am dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 AM the Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. 2. On 1/28/2024 at 9:00 AM, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. 3. On 01/28/2024 at approximately 10:42 AM Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 AM the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 PM the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 AM the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 AM. 7. On 1/29/2024 at approximately 10:30 AM Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 PM Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 PM to 7:00 AM on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 PM Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. Validation On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the no[TRUNCATED]

**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 medications were administered to prevent discomfort or complications for four (4) of 14 residents reviewed with medication errors. This resulted in significant medication errors for Resident #1, Resident #3, Resident #4, and Resident #5. The facility did not have licensed nurse coverage for twenty-five (25) residents on the Annex A Hall of the facility for eight (8) hours from 11:00 PM through 7:00 AM on 1/27/24. Resident #1 Resident #3, Resident #4, and Resident #5 had scheduled medications to be administered at 6:00 AM. The significant medications which were missed included anti-coagulants, anti-seizure, anti-diabetic (insulin), diuretic, and pain management medications. This placed the residents at risk and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/02/24, which began on 1/27/24, when the facility's failure to ensure sufficient licensed nurse was present to provide necessary nursing services. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Templates. The facility submitted an acceptable Removal Plan on 2/02/24 at 9:52 PM, in which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/02/24 and the IJ was removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ and SQC was removed on 2/03/24, prior to exit. Therefore, the scope and severity for CFR 483.45(f)(2) (F760)- Residents are free from any significant medication errors, was lowered from an J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Administering Medications, revised April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation: 3.) Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions .4.) Medications are administered in accordance with prescriber's orders, including any required timeframe.5.) Medication administration times are determined by the resident need and benefit, not staff convenience. Review of the facility policy titled, Adverse Consequences and Medication Errors, revised February 2023, revealed, Medication Errors: 1.) A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer guidelines, or accepted professional standards and principles of professionals providing services.5.) In the event of a significant medication-related error. Take action, to protect the resident's safety and welfare .6.) Promptly notify the provider of any significant error. Record review of the facility schedule/time sheets for 1/27/24 revealed the facility did not have licensed nurse coverage for twenty-five (25) residents on the Annex A Hall of the facility for eight (8) hours from 11:00 PM through 7:00 AM. On 1/31/24 at 1:00 PM, during a phone interview with Licensed Practical Nurse (LPN) #2, she confirmed she counted the medication cart with LPN #1 on 1/27/24 at 11:00 PM so LPN #1 could go home. She revealed she was assigned to the 100 Hall and only counted the narcotics for the Annex A cart until someone came in. She confirmed she did not administer the 6:00 AM medications or monitor the residents on Annex A hall because she was assigned to the 100 Hall and was unable to take care of residents and administer medications for two halls. On 1/31/24 at 2:30 PM, a phone interview with LPN #3 revealed she worked on 1/27/24 from 7:00 PM-7:00 AM but she was unaware that the Annex A cart did not have a nurse assigned to it and confirmed she did not monitor any residents on the Annex A hall and did not know they did not get their morning medications. On 2/1/24 at 10:50 AM, an interview with LPN #1, she revealed when she returned to work on 1/28/24 at 7:00 AM there was not a nurse assigned to the Annex A medication cart and she noticed the 6:00 AM medications had not been signed off as administered. On 2/2/24 at 10:00 AM, in an interview with the Administrator, she stated that she was not aware that there was no nurse for on the Annex A hall from 11:00 PM until 7:00 AM on 1/27/24, and that the residents did not receive their 6:00 AM medications for 1/28/24 until around 7:00 AM. She stated that the residents on Annex A hall were assessed by the RN supervisors on 1/28/24. On 2/2/24 at 10:05 AM, an interview with the Assistant Director of Nursing (ADON) revealed that failure to administer insulin, anticonvulsants, blood thinners and scheduled pain medications could lead to hyperglycemia, seizures, and unrelieved pain. On 2/2/24 at 10:20 AM, during an interview with the Staff Development Coordinator (SDC), she found out at 8:15 AM on 1/28/24 that Residents #1, #3, #4 and #5 did not receive their 6:00 AM medications. Resident #1 Review of the physician order for Resident # 1 revealed an order dated 10/12/23 for Apixaban Oral Tablet 5 mg (milligram) give one tablet by via peg-tube (percutaneous endoscopic gastrostomy) two times daily related to Cerebral Infarction. Review of the January 2024 Medication Administration Record for Resident #1 revealed Apixaban Oral Tablet 5 mg (milligram) was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #1 to the facility on [DATE] with diagnoses including Respiratory Failure, Hemiplegia, and Cerebral Infarction. Resident # 3 Review of a physician orders for Resident # 3 revealed an order dated 6/25/20 revealed Lacosamide tablet 100 mg: give one tablet by mouth two times daily related to seizures and.Keppra tablet 500 mg: give one tablet by mouth two times daily related to seizures. Review of the January 2024 Medication Administration Record for Resident #3 revealed. Lacosamide tablet 100 mg and Keppra tablet 500 mg was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #3 to the facility on 6/26/20 with diagnoses including Epilepsy. Resident #4 Review of a physician orders for Resident # 3 revealed an order dated 7/13/23, revealed Norco Oral tablet 7.5-325 mg (Hydrocodone Acetaminophen): give one tablet enterally every eight hours related to pain. Review of the January 2024 Medication Administration Record for Resident #4 revealed, Norco oral tablet 7.5-325 mg was not signed as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #4 to the facility on 6/02/23 with diagnoses including Anxiety and Pain in unspecified joint. Resident #5 Record review of physician orders for Resident # 5 revealed an order dated 9/11/23, revealed, Insulin Glargine Solution 100 units/ml: inject 8 units subcutaneously in the morning related to Type 2 (two) Diabetes. Record review of physician orders for Resident # 5 revealed an order dated 1/23/24, revealed, Furosemide 40 mg tablet: take one tablet by mouth twice daily before meals related to Hypertensive Heart Disease. Review of the January 2024 Medication Administration Record for Resident # 5 revealed, Insulin Glargine Solution 100 units/ml: inject 8 units subcutaneously and Furosemide 40 mg tablet, was not signed off as administered on 1/28/24 at 6:00 AM. Record review of the admission Record revealed that the facility admitted Resident #5 to the facility on 6/17/22 with diagnoses including Type 2 Diabetes and Hypertensive Heart Disease. REMOVAL PLAN On 2/2/2024 at 12:20 P.M. State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this removal plan. Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00pm to 7:00 am on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6 am medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 am medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 am dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 AM. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. The facility submitted an acceptable Removal Plan for the IJ on 2/2/24 at 9:52 PM. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ on 2/02/24: Validation On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, and staff interviews that on, in-services were initiated, and staff on duty has received the in-services. The SA validated on 2/3/24, that all corrective actions had been taken by the facility to remove the IJ during the survey on 2/2/24 and the IJ was removed on 2/3/24.

Based on facility policy review, record review, staff interviews, and resident interviews the facility administration failed to use its resources effectively and efficiently to ensure licensed staff was available to provide care for twenty-five (25) of (53) residents on the Annex Unit with for eight (8) hours on 1/27/24 from 11:00 PM through 7:00 AM on 1/28/24. The Licensed Practical Nurse (LPN) who was scheduled to report at 7:00 PM on 1/27/24 did not arrive for her shift at the facility. LPN #1 had worked since 7:00 AM and left the facility at 11:35 PM on 1/27/24. LPN # 2 counted the narcotic cart for Annex A hall and took the keys to the cart but did not accept responsibility for the twenty (25) residents on the Annex A hall of the facility. The Administrator, Director of Nursing (DON), and Staff Development Coordinator (SDC) were aware that the scheduled LPN did not report for her shift. Staff and agency nurses did not respond to the call for replacement. No licensed nurse reported to duty on the Annex A hall of the facility between 11:35 PM and 7:00 AM. The facility failed to follow its stated practice for replacing staff in case of call-ins or no call, no shows. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staff Development Coordinator (SDC) were aware of the staffing problem. The On-Call SDC failed to report to duty related to limitations. The facility' s failure to provide administrative oversight and supervision to ensure sufficient nursing staff to provide supervision, care and services placed residents on the South Unit at risk, and in a situation likely to cause serious injury, serious impairment, serious harm, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) on 2/02/24, which began on 1/27/24, when the facility failed to ensure sufficient licensed nurse was present to provide necessary nursing services. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and provided the facility with the IJ Templates. The facility submitted an acceptable Removal Plan on 2/02/24 at 9:52 pm, in which the facility alleged all corrective actions to remove the IJ and SQC were completed on 2/02/24 and the IJ was removed as of 2/03/24. The SA validated the Removal Plan on 2/03/24 and determined the IJ was removed on 2/03/24, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1) Abuse and Neglect (F 600), was lowered from a J to a D while the facility develops and implements a plan of correction to monitor 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, Sufficient and Competent Nursing, reviewed 3/2023, revealed, Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans .Minimum staffing requirements imposed by the state .are not necessarily considered a determination of sufficient and competent staffing. A record review of the Job Description: Facility Administrator, dated March 2017, revealed Basic Function: Responsible for the overall management .of the facility .Supervisory Responsibilities: The Administrator supervises the Director of Nursing .Essential Functions and Responsibilities: Operations .Ensures that the quality and appropriateness of resident care meets or exceeds company and industry standards and ensures compliance with state and federal legal, regulatory, accreditation and reimbursement guidelines. Record review of facility Daily Staffing Sheet revealed no licensed staff was on duty for the Annex A hall of the facility from 11:35 PM on 1/27/24 through 7:00 AM on 1/28/24. During an interview with the ADON on 2/1/24 at 4:00 PM, he stated that it is the facilities practice that the Registered Nurses (RN) take a call rotation and come in and work the medication cart if someone called in and coverage could not be found. In an interview with the Administrator on 2/2/24 at 10:00 AM, she stated that she was not aware that there was no nurse for Annex Cart A from 11:00 PM until 7:00 AM on 1/28/24. In an interview on 2/2/24 at 10:20 AM, with the Staff Development Coordinator she stated that on 1/27/24 at 7:49 PM she received a text from Licensed Practical Nurse #1(LPN) notifying her that the night nurse had called in. The SDC stated she text the Administrator, DON, and ADON at 7:55 PM. She stated that she then sent a text out to nurses to attempt to get the shift covered, but no one was available. The SCD stated that she notified the Administrator, DON, and ADON that there was no coverage. The SDC stated that no one accepted the shift from the agency website. During a further interview with the SDC she verified that she was the RN on call for 1/27/24, but that she is on light duty and cannot push a medication cart. She stated that she was only on call as a supervisor to attempt to find coverage for call ins. In a telephone interview with the DON on 2/2/24 at 10:45 AM, she stated that she received a phone call at 8:00 PM on 1/27/24, notifying her that the 7:00 AM to 7:00 PM nurse for the Annex had called in. The DON stated that she asked the SCD if she had reached out to all of the nurses that normally worked and the SCD told her that she had but no one could pick up the shift. The DON further stated that she had fallen asleep and reached back out at 10:55 PM to the SCD asking what the plan for that cart was. She stated that the SCD told her that no one had responded to the shift posted on the agency website and that LPN #1 left. The DON stated she reached back out to the SCD around 1:27 AM but there was still no nurse. The DON stated that at some point the ADON had informed her that he was out town and could not cover the shift. The DON stated that she was also out of town and could not cover the shift. The DON stated that she knew the SDC was the nurse on call and if the on-call nurse cannot find coverage then they are to come in and work the cart. The DON stated that she was aware of the SDC's medical restrictions but did not think about the SDC's limitations when she was notified there was no nurse for the Annex A hall. She stated that she did not think about needing someone to cover for her or the ADON due to them being out of town, or the SDC related to her medical restrictions. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Brief Summary of Events On 1/27/2024 the facility did not have a licensed practical nurse from 11:00 PM to 7:00 AM on Annex cart A. During this time fourteen (14) of twenty-five (25) residents were identified as not receiving the 6:00 AM medication dose. On 1/28/2024 an investigation was initiated by the Director of Nursing. Licensed Practical Nurse #1 assigned to Annex Cart B stated that she rounded on the twenty-five (25) residents that resided on Annex Cart A but did not administer the 6 AM medications. As a result of this investigation medication error reports were initiated and orders were received from the Nurse Practitioner to omit the 6 AM dose and continue the regular dosing schedule and monitor the fourteen (14) residents for any adverse effects. Corrective Actions 1. On 01/28/2024 at approximately 9:00 A.M. The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 am medications. fourteen (14) residents were identified as missing one or more medications at 6 am on 1/28/24. 2. On 1/28/2024 at 9:00 A.M., the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00pm to 7:00 am. 3. On 01/28/2024 at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications. No adverse events were found. 4. On 1/28/2024 at approximately 11:35 A.M. the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. 5. On 1/28/2024 at approximately 1:00 P.M. the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. 6. On 1/29/2024 at approximately 9:30 A.M. the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. 7. On 1/29/2024 at approximately 10:30 A.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 held Ad hoc Quality Assurance Performance Improvement Meeting to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 8. On 02/02/2024 at approximately 3:30 P.M. Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. 9. On 02/02/2024 at approximately 4:00 P.M. Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision. No adverse events found. 10. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. 11. On 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff will be allowed to return to work without completing. 12. On 2/2/2024 at 5:15 P.M. Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision. No adverse effects found. 13. On 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 14. On 2/2/2024 at 5:30 P.M. the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. 15. On 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects due to the lack of nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 P.M. 16. On 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. 17. Beginning 02/02/2024 at approximately 6:00 P.M. the Interim Director of Nursing began Competency skills check offs on licensed nurses regarding the five rights of medication administration. 18. On 2/2/2024 at 6:30 P.M. the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. 19. On 2/2/2024 at 6:30 P.M. the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. 20. On 02/02/2024 at 7:00 P.M. Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. 21. On 2/2/2024, in-services were initiated, and no staff will be able to work until receiving in-service. 22. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/02/2024 and the Immediate Jeopardy was removed 02/03/2024. Validation On 2/3/24, the SA surveyor validated through staff interview, resident interview, record review, sign-in sheets, and in-service reviews that the facility had implemented the following measures to remove the Immediate Jeopardy (IJ): The SA verified through record reviews, and staff interviews that on 01/28/2024, The Director of Nursing conducted an Audit on all residents residing on Annex Cart A to identify the residents that missed 6 AM medications. fourteen (14) residents were identified as missing one or more medications at 6 AM on 1/28/24. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Infection Preventionist initiated facility-based incident reporting on the fourteen (14) residents identified as missing one or more medications on 1/27/2024 from 11:00 PM to 7:00 AM. The SA verified through record reviews, and staff interviews that on 01/28/2024, at approximately 10:42 A.M. Registered Nurse (RN) #1 initiated assessments on the fourteen (14) residents that were missing one or more medications for any adverse events associated with the missing medications and that adverse events were found. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Registered Nurse #1 initiated the notification to the responsible parties and the Nurse Practitioner (NP) of the fourteen (14) residents with missing medication. Orders were obtained from the Nurse Practitioner (NP)for the fourteen (14) identified residents with missing medications. The SA verified through record reviews, and staff interviews that on 1/28/2024, the Staff Development Coordinator reviewed the staffing schedules for licensed nurses to ensure adequate licensed staff was present on each shift to meet resident needs. The SA verified through record reviews, and staff interviews that on 1/29/2024 the Director of Nursing initiated the medication error reports on fourteen (14) identified residents who missed medications on 1/28/2024 at 6 A.M. The SA verified through record reviews, and staff interviews that on 1/29/2024 a Quality Assurance Performance Improvement meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2, and Registered Nurse Supervisor #1 to include assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, staff, and resident interviews that on 02/02/2024, a Resident Council Meeting was held with the Activity Director, Resident Council President, and 31 total resident members were present to inform them the facility received six (6) Immediate Jeopardies for no nursing supervision on 1/27/2024 from 11:00 P.M. to 7:00 A.M. on Annex Cart A resulting in missed medications. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Nurse Practitioner (NP) initiated the assessments of the twenty (25) residents that resided on Annex Cart A for any adverse events related to missed administration of medications and the lack of nursing supervision with no adverse events found. The SA verified through record reviews, and staff interviews that on 02/02/2024, the Staff Development Coordinator initiated education with all licensed nurses on the five rights of medication administration with ongoing and off going narcotic counts, obtaining keys and accountability of maintaining those keys, and accepting responsibility of the medication cart. No staff will be allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 02/02/2024 beginning at 4:30 P.M. Staff Development Coordinator initiated education with all staff to include Certified Nursing Assistants, Licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff, and administrative staff on Abuse and Neglect, Resident Rights, Vulnerable Adult Act, Reporting Requirements, Adequate Staffing, and Notification of the Staff Development Coordinator, Director of Nursing and Administrator when significant events in the facility occur. No staff was allowed to return to work without completing. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Registered Nurse Supervisor #1, Registered Nurse Supervisor #2, and Registered Nurse #3 begin assessing the remaining Eleven (11) of the twenty (25) residents for adverse effects related to lack of nursing supervision with no adverse effects found. The SA verified through record reviews, and staff interviews that on 02/02/2024 at approximately 5:15 P.M. the Assistant Director of Nurses #2 contacted the Nurse Practitioner (NP) and orders for labs were obtained and lab draws were initiated by Registered Nurse Supervisor #3 and Registered Nurse Supervisor #4 to ensure no abnormalities due to missed medications and lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Interim Director of Nursing and the Assistant Director of Nursing #2 initiated facility-based incident reports on the eleven (11) remaining residents that resided on Annex cart A on 1/27/2024 from 11:00 P.M. to 7:00 A.M. due to lack of nursing supervision. The SA verified through record reviews, and staff interviews that on 02/02/2024 at 5:30 P.M. the Minimum Data Set (MDS) nurse-initiated care plans on the twenty-five (25) residents that resided on Annex Cart A to include monitoring for adverse reactions to missed medication dose and the monitoring of any adverse effects. The SA verified through record reviews, and staff interviews that on 2/2/2024 at 5:45 P.M. the Registered Nurse Supervisor #1 notified the responsible parties for the remaining eleven (11) residents that resided on Annex cart A of the incident that occurred 1/27/2024 relating to the lack of nursing supervision from 11:00 P.M. to 7:00 A.M. The SA verified through record reviews, and staff interviews that on beginning 02/02/2024. The Interim Director of Nursing began competency skills check offs on licensed nurses regarding the five rights of medication administration. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Minimum Data Set (MDS) nurse received education on developing and implementing a comprehensive person-centered care plan, and the timeliness of the resident person-centered care plan by the Regional Case mix reimbursement. The SA verified through record reviews, and staff interviews that on 2/2/2024 the Administrator and the Director of Nursing received education on proper Abuse and Neglect reporting, investigation guidelines following the state and federal regulations by the Corporate Clinical Specialist. The SA verified through record reviews, and staff interviews that on 02/02/2024 a Quality Assurance Performance Improvement Meeting was held with the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing #1, and Assistant Director of Nursing #2 to address the notification of Immediate Jeopardy and to review steps initiated to prevent any further reoccurrence including assessments, audits of missed medications, plans to monitor for adverse effects, ensuring adequate staffing, care plan development, timely reporting, and ensuring the proper communication channels are followed in regards to staffing issues or significant events by notification of Staff Development Coordinator, Director of Nursing and Administrator. The SA verified through record reviews, and staff interviews that on, in-services were initiated, and staff on duty has received the in-services. The SA validated on 2/3/24, that all corrective actions had been taken by the facility to remove the IJ during the survey on 2/2/24 and the IJ was removed on 2/3/24.