**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care according to professional standards of practice when suffering a change in condition for 1 of 3 residents reviewed, Resident #1. On 4/9/2024 at 12:45 AM, Resident #1 had a blood sugar value of 72, Staff A, Licensed Practical Nurse (LPN), did not contact the provider and administered glucose gel without a physician's order. On 4/9/2025 at 1:49 AM, Resident #1 was less responsive. On 4/9/2025 at 3:00 AM, Resident #1 had a blood sugar value of 42. The on-call physician was called, and ordered to administer Glucagon intramuscularly, monitor, and send to the emergency room if no positive response to Glucagon received. On 4/9/2025 at 5:30 AM, Resident #1 had a blood sugar value of 50. The blood sugar value was rechecked with a blood sugar value of 50. Resident #1 was not responding to verbal or physical stimuli. The provider was not notified, Glucagon was not administered per physician's order when blood sugar dropped below 60 a second time, and the resident was not sent out to the emergency room per the physician's order. On 4/9/2025 at 6:30 AM, Resident #1 had a blood sugar value of 32. Glucagon was not administered per the physician's order. Emergency Medical Services, 911, were called and Resident #1 was transported to a local hospital. Resident #1 did not survive. This failure places all 118 current residents who may possibly suffer a change in condition at risk. The facility's failure to implement the policies and procedures for change in condition, notifying the physician of a change in condition, and not following physician's orders led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Administrator was notified of the Immediate Jeopardy on May 2, 2025 at 3:15 PM. Findings include: Review of Resident #1's physician order dated 3/12/2025 at 1:46 PM read, Perform Accuchek [testing of blood glucose] before meals and at bedtime related to Type 2 Diabetes Mellitus with foot ulcer. Review of Resident #1's physician order dated 4/8/2025 at 6:41 PM read, Glucagon Emergency Injection Kit 1 MG [milligram] [glucagon for injection], Inject 1 application subcutaneously as needed for Administer [Sic.] if BS [blood sugar] <60 [less than 60] recheck sugar Q2H [every 2 hours]. Review of Resident #1's progress note dated 4/9/2025 at 12:45 AM read, Received with low blood sugar rechecked with a 72 result [American Diabetes Association recommended blood sugar range for adults with Type II Diabetes is 80 to 130] . responsive with eyes and asked if he wants to go to ER [Emergency Room] and he shook head no, oral [glucose] gel [used for people with diabetes to raise their blood sugar levels] received and able to swallow. Review of the 5-Day Entry Minimum Data Set, dated [DATE] read, BIMS 14 [Brief Interview for Mental Status - cognition is considered intact]. Review of Resident #1's physician orders for 4/9/2025 did not provide documentation of an order for glucose gel. Review of Resident #1's Medication Administration Record for the period of 3/12/2025 through 4/8/2025 documented blood sugar values between 80 and 220. Review of Resident #1's nursing progress notes for 4/9/2025 did not provide documentation of Resident #1's physician being notified of Resident #1's blood sugar value and the administration of glucose gel. Review of Resident #1's progress note dated 4/9/2025 at 1:49 AM read, Less responsive. Review of Resident #1's progress note dated 4/9/2025 at 3:00 AM read, Monitoring blood sugar with results of 42, unstable blood sugar. On call MD [Medical Doctor covering for Medical Doctor #1] contacted with report of cond. [condition] orders to give the glucagon at this time IM [intramuscular]. Review of Resident #1's Medication Administration Record for the month of April 2025 documented Glucagon Emergency Kit 1 mg was administered on 4/9/2025 at 3:12 AM. Review of Resident #1's progress note dated 4/9/2025 at 3:50 AM read, Glucagon given SQ [subcutaneous] to left arm per order of the on call for [Medical Doctor #1's name, Advanced Practice Registered Nurse (APRN)#1's name], monitor and send to ER if no positive response to Glucagon. Review of Resident #1's progress note dated 4/9/2025 at 6:15 AM read, INC [incontinent] of large amount of loose stool, BS rechecked x 2 [times two] 50 result at 0530 [5:30 AM], not responding to verbal or physical stimuli, rechecked blood sugar 0630 [6:30 AM] with result of 32 [Normal blood sugar values are between 70-99, a value of 32 is considered hypoglycemia, a dangerous condition that requires immediate medical attention]. 911 notified of ER [Sic.] with response team arriving at 0630. After evaluation of team sent to ER. Review of Resident #1's physician order dated 4/9/2025 at 7:00 AM read, Send to ER for hypoglycemia without response to Glucagon tx [treatment]. Review of Resident #1's progress note dated 4/11/2025 at 10:07 PM read, Resident expired at the hospital 4/9. Review of Resident #1's care plan dated 3/24/2025 read, Focus: [Resident #1's name] is here for short stay placement r/t [related to] CHF [congestive heart failure]/weakness. Resident/representative clearly express desire to discharge from facility. Plans to discharge facility when medically cleared . Focus: [Resident #1's name] has a strength in communication AEB [as evidenced by] is able to hear at normal tones, speech is clear and easily understood. Communicates needs to staff. During a telephonic interview on 4/30/2025 at 10:10 PM, Staff A, Licensed Practical Nurse (LPN), stated, I do remember [Resident #1's name]. At the beginning of my shift [11:00 PM -7:00 AM], I checked him, he was awake, alert, taking juice and took the glucose gel. I checked his blood sugar, but I do not think I charted the blood glucose. His level would go up and then go back down. When I called the on-call provider for [Medical Doctor #1's name], she said her name was [First Name of APRN #1] and I asked if he should go to the ER and she [APRN #1] said to give him Glucagon. When I checked his [Resident #1's] blood glucose afterward it went up, I went back to check on him at end of shift and that is when his blood glucose had dropped, and I called 911. During an interview on 4/30/2025 at 11:45 AM, the Director of Nursing (DON) stated, We review 100% of all transfers to acute care facilities. QI [Quality Improvement] tool utilized for review of acute care transfers. We check care that was provided 72 hours prior to transfer to determine if there are any opportunities for improvement and to identify if there are any reportable events. The reviews are conducted by the two nurse managers and myself. The nurse managers generally review the charts for residents that were transferred from their units to an acute care facility. [Resident #1's name] was not identified to be a Federal or State reported event because record review did not identify any areas in need of improvement at the time of review and there were no complaints received about this resident. I am trying to get nursing to complete the interact SBAR [Situation, Background, Assessment, and Recommendation] anytime there is a change in condition. During an interview on 4/30/2025 at approximately 12:00 PM, Staff C, LPN, Unit Manager, confirmed that she had conducted the chart review for Resident #1 and stated The nurse followed the physician order. The order stated to check the blood sugar Q [every] 2 hours after Glucagon was given. During an interview on 5/1/2025 at 7:25 AM, Staff A, LPN, stated, I did check the resident's [Resident #1's] blood sugar more often than is documented. At least every 30 minutes. During an interview on 5/1/2025 at approximately 7:55 AM, the DON stated, Nurses should follow the physician orders and if Glucagon is ordered, they should check the BS in 30 minutes. I know why [Staff A's name] said 30 minutes because the orders are usually written to recheck in 30 minutes not Q2 hours. We have a policy, but it does not include the use of glucagon. When asked regarding the quality review of Resident #1's return to the hospital and the findings, the DON stated, There was documentation issues and post administration blood sugars were not documented. Blood sugar levels that were taken should have been documented and a blood sugar should have been taken 15 minutes after glucagon administration. During a telephonic interview on 5/1/2025 at 9:17 AM, the Medical Doctor #1 stated, My expectation is that the professional standards for management of hypoglycemia should be followed which includes administration of emergency Glucagon, rechecking blood glucose in 15 minutes and reassessing the resident. The physician should be notified of the condition change and if life threatening contact emergency management services for transport to the hospital. During a telephonic interview on 5/1/2025 at 9:30 AM, the Medical Director stated, I expect that professional standards of practice should be followed. After Glucagon administration, the blood sugar should be checked in 15 minutes. I would not order blood sugar to be checked every two hours. If the resident is not responding, emergency management services should be contacted for transport to the hospital. During a telephonic interview on 5/1/2025 at 9:50 AM, the APRN #1 stated, It is my expectation that professional standards of practice should be followed by nursing when a resident is hypoglycemic. I give an order for glucagon and to recheck the blood sugar in 15 minutes and to call me back. During a telephonic interview on 5/2/2025 at 1:50 PM, the Medical Director stated, If a resident has a blood sugar of 32, I will give [glucagon injection] immediately and if symptomatic, I would send them out to the emergency room immediately. Low blood sugar causes circulatory depression, fogginess, and a change in mental condition. The resident diagnoses need to be considered. Many medications are secreted in the kidneys. The resident would need to have intravenous drip and lab work. I did not know about this patient until yesterday [5/1/2025]. Review of manufacturer's medication insert provided by the DON read, [Glucagon injection] is the first FDA [Food and Drug Administration]-Approved autoinjector for very low blood sugar that is premixed and ready-to-use. It is a prescription medicine used to treat very low blood sugar (severe hypoglycemia) in adults and children ages 2 years and above with diabetes. [Glucagon injection] reduces the steps to prepare and administer glucagon in the event of severe hypoglycemia (i.e., dangerously low blood sugar levels). This innovation is designed to provide the reliability of a ready-to-use liquid glucagon while making it simple for patients or caregivers to administer. Severe hypoglycemia occurs when your blood sugar gets so low that you need help bringing it back up. Sometimes people with very low blood sugar may have a hard time thinking straight or controlling their body, get very tired, refuse to eat, pass out, or even have a seizure. It is an emergency situation that must be treated immediately. Indication and Important Safety Information: [Glucagon injection] e is indicated for the treatment of severe hypoglycemia in adult and pediatric patients with diabetes ages 2 years and above. Review of the facility policy and procedure titled Diabetes/Hypo/Hyperglycemia with the last review date of 1/16/2025 read, Policy: It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize the risk of hypo/hyperglycemia. Procedure: 1. Residents diagnosed with diabetes mellitus (or other conditions requiring blood glucose monitoring and control) will receive insulin, oral hypoglycemic medications and/or an individually prescribed diet according to the physician order . 4. The physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters such as glycosuria, weight gain or loss, hypoglycemic episodes, etc. 5. Staff will provide glucose monitoring, medication administration, laboratory testing, and diet per physician's orders . 7. Staff should report signs and symptoms of hypoglycemia to the physician. Many residents receive insulin or oral hypoglycemic that have parameters as to when the physician should be notified. 8. Staff will identify and report complications such as foot infections, skin ulceration, increase thirst, changes in pain levels, or changes in mentation/level of consciousness and notify the physician for orders . 10. Nursing interventions, per physician orders, may vary for residents experience hypoglycemia depending on the severity and symptoms of the resident as residents' behavior is different depending on their sensitivity to hypoglycemia. Responsive residents that are able to swallow may receive juice or other rapidly absorbed glucose as an intervention. Responsive residents that aren't unable to swallow or unresponsive residents may receive oral glucose paste to the buccal mucosa, intramuscular Glucagon, or IV [intravenous] 50% dextrose and notify the physician for further orders. 14. Document pertinent information regarding medication administration, change in condition, education or interventions in clinical record. Review of the facility policy and procedure titled Change in Condition with the last review date of 1/16/2025 read, Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident presentative (as is applicable) of significant changes in condition and providing treatment(s) according to the resident's wishes and physician's orders. Procedure: 1. Observed the resident during routine care during monthly/quarterly/annual assessment periods to identify significant changes in physical or mental conditions, orientation, change in vital signs, weights, etc. 2. When a change is noted, gather pertinent data such as vital signs, weights and other clinical observation. 3. If the resident is able to make his/her own decision regarding medical care, solicit their choice of action in relation to the perceived change of status. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident (if applicable) to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 5. Contact licensed co-workers for assistance if the change in condition is considered potentially life threatening. 6. In the event the change in condition is considered life threatening, the clinical record should be reviewed as soon as possible to determine the resident's wishes regarding hospitalization, CPR [cardiopulmonary resuscitation] or DNR [do not resuscitate]. 7. Contact the primary physician to update him /her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 8. If the resident's condition is considered to be life threatening and the resident requires immediate medical care, notify the emergency medical system (or 911). Review of the Reference Mayo Clinic on 5/1/2025 at https://www.mayoclinic.org/drugs-supplements/glucagon-injection-route/description/drg-20064089 read, Glucagon injection is an emergency medicine used to treat severe hypoglycemia (low blood sugar) in diabetes patient treated with insulin who have passed out or cannot take some form of sugar by mouth. For injection dosage forms (autoinjector or prefilled syringe): Adults and children [AGE] years of age and older - I milligram (mg) or 0.2 milliliter (ml) injected under your skin. An additional dose of 1 mg or 0.2 ml may be repeated if there has been no response after 15 minutes while waiting for emergency assistance. Precautions with diabetes should be aware of the symptoms of hypoglycemia (low blood sugar). These symptoms may develop in a very short time and may result from *using too much insulin (insulin reaction) or as a side effect from oral antidiabetic medicines. * delaying or missing a schedule smack or meal * sickness (especially with vomiting and diarrhea) * exercising more than usual. Unless corrected, hypoglycemia will lead to unconsciousness, seizures, and possibly death. Early symptoms of hypoglycemia include: anxious feeling, behavior change similar to being drunk, blurred vision, cold sweats, confusion, cool pale skin, difficulty in concentrating, drowsiness, excessive hunger, fast heart beat, headache, nausea, nervousness, nightmares, restless sleep, shakiness, slurred speech, and unusual tiredness or weakness. After the injection, turn the patient on his or her left side. Glucagon may cause some patients to vomit and this position will reduce the possibility of choking. The patient should become conscious in less than 15 minutes after glucagon is injected, but if not, a second dose may be given. Get the patient to the doctor or to hospital emergency care as soon as possible because being unconscious too long may be harmful. When the patient is conscious and can swallow, give him or her some form of sugar. Glucagon is not effective for much longer than 1 1/2 hours and is used only until the patient is able to swallow fruit juice, corn syrup, honey and sugar cubes or table sugar dissolved in water all work quickly then if a snack or meal is not scheduled for an hour or more the patient should also eat some crackers and cheese or half a sandwich or drink a glass of milk this will prevent hypoglycemia from occurring again before the next meal or snack. The patient or caregiver should continue to monitor the patient's blood sugar for about 3 to 4 hours after the patient regains consciousness. The blood sugar should be checked every hour if nausea and vomiting prevent the patient from swallowing some form of sugar for an hour after Glucagon is given. Medical help should be obtained. The facility submitted an acceptable Immediate Jeopardy removal plan with the removal date of May 1, 2025. The survey team verified the implementation of the facility's immediate actions to remove the immediate jeopardy to include: On 4/30/2025, the DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders for the last 30 days including administration of hypoglycemia interventions with documentation of repeat blood sugars. On 4/30/2025, the DON/designee completed a review of residents who return to the hospital over the past 30 days to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out. On 4/30/2025, the DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered. On 5/1/2025, an Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis. On 5/1/2025, Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition. On 5/1/2025, the facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated. By 5/1/2025, 32 out of 33 licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated. Review of the audits showed all active residents in the facility with orders for blood sugar monitoring and insulin administration (32) was reviewed to identify concerns related to insulin administration with the physician orders for the last 30 days with no concerns identified. Review of the audits showed 44 residents were reviewed for changes in condition related to possible hypoglycemia, change in condition, validation of physician notification, physician orders, and implementation of orders over the last 30 days with no concerns identified. During staff interviews conducted on 5/2/2025, seven LPNs and two RNs verified receiving the training and verbalized understanding of diabetes management, policy and procedure on change in condition, anti-hypoglycemia administration and interventions, notification of the DON/ADON when hypoglycemic interventions initiated, documentation of results, and following up with the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical, physical, mental, and psychosocial well-being of each resident by failing to implement policies and procedures related to change in condition for 1 of 3 residents reviewed, Resident #1. On [DATE] at 12:45 AM, Resident #1 had a blood sugar value of 72, Staff A, Licensed Practical Nurse (LPN), did not contact the provider and administered glucose gel without a physician's order. On [DATE] at 1:49 AM, Resident #1 was less responsive. On [DATE] at 3:00 AM, Resident #1 had a blood sugar value of 42. The on-call physician was called, and ordered to administer Glucagon intramuscularly, monitor, and send to the emergency room if no positive response to Glucagon received. On [DATE] at 5:30 AM, Resident #1 had a blood sugar value of 50. The blood sugar value was rechecked with a blood sugar value of 50. Resident #1 was not responding to verbal or physical stimuli. The provider was not notified, Glucagon was not administered per physician's order when blood sugar dropped below 60 for a second time, and the resident was not sent out to the emergency room per the physician's order. On [DATE] at 6:30 AM, Resident #1 had a blood sugar value of 32. Glucagon was not administered per the physician's order. Emergency Medical Services, 911, were called and Resident #1 was transported to a local hospital. Resident #1 did not survive. This failure places all 118 current residents who may possibly suffer a change in condition at risk. The facility's failure to implement the policies and procedures for change in condition, notifying the physician of a change in condition, and not following physician's orders led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:15 PM. Findings include: Review of the Administrator's job description acknowledged on [DATE], read, Purpose of Your Job Position: The primary purpose of your position is to direct the day to day functions of the Facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to all our residents at all times . Duties and Responsibilities. Administrative Functions: Plan, develop, organize, implement, and evaluate and direct the Facility's programs and activities. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility . Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures . Committee Functions . Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies . Personnel Functions . Assist the Medical Director in the development and implementation of medical and nursing services policies and procedures and professional standards of practice. Inform the Medical Director of all suspected or known incidents of resident abuse. Review of the Director of Nursing's job description acknowledged on [DATE], read, Purpose of Your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times . Duties and Responsibilities. Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Develop, maintain, and periodically update written policies and procedures that govern the day-to-day functions of the nursing service department. Maintain a reference library of written nursing materials (i.e. PDR's [Physician's Desk References], Regulations, Standards of Practice, etc.) that will assist the nursing service department in meeting the day-to-day needs of the resident. Make written, and oral reports and recommendations to the Administrator concerning the operation of the nursing service department. Develop, implement, and maintain an ongoing quality assurance program for nursing service department . Perform administrative duties such as completing medical forms, reports, evaluation, studies, charting, etc., as necessary. Monitor the Facility's QI, QM [Quality Improvement/Quality Management] and survey reports. Assist in developing plans of action to correct potential or identified problem areas . Personnel Functions: Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents . Nursing Care Functions . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and such care is provided in accordance with the residents wishes. Review of the Assistant Director of Nursing Service's job description acknowledged on [DATE] read, Purpose of Your Job Position: The primary purpose of your position is to assist the Director of Nursing Services in planning, organizing, developing, and directing the day to day function of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our Facility, and as may be directed by Administrator, the Medical Director, and/or the Director of Nursing Services to ensure that highest degree of quality care is maintained at all times. Delegation of Authority: As Assistant Director of Nursing Services you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In absence of the Director of Nursing Services, you are charged with carrying out the resident care policies established by this Facility. Duties and Responsibilities. Administrative Functions: Assist the Director of Nursing Services (the Director) in planning, developing, organizing, implementing, evaluating, and directing the day-to-day operations of the nursing service department, in accordance with the current rules, regulations, and guidelines that govern the Facility. Participate in developing, maintaining, and updating our education, written policies and procedures that govern the day-to-day functions of the nursing service department . Make written and oral reports or recommendations to the Director concerning the operation of the nursing service department, as necessary . Ensure that all nursing service personnel are following their respective job descriptions. Monitor the Facility's QI/QM and survey reports and provide the Director with recommendations that will be helpful in eliminating problem areas . Participate in the development, maintenance, implementation, and updating of the written policies and procedures for the administration, storage, and control of medications and supplies. Committee Functions . Serve on the Quality Assurance and Assessment Committee, as directed . Personnel Functions . Make daily rounds of nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report findings to the Director . Nursing Care Functions . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the residents' wishes. Schedule daily rounds to observe residents and to determine if nursing needs are being met. Report problem areas to the Director. Assist in developing and implementing corrective actions. Review of the Medical Director's Agreement read, Performance Requirements and Duties and Responsibilities of a Nursing Facility Medial Director. Exhibit A: 'Medical Director Services' - agreement in writing to accept legal responsibility for those activities of the facility pursuant to §400.9935 Florida statutes; Ensuring that all practitioners providing health care services or supplies to patients maintain a current active and unencumbered Florida license; reviewing any patient referral contracts or agreements executed by the clinic; ensuring that all health care practitioners at the facility have active appropriate certification or licensure for the level of care being provided; serving as clinic record owner as defined in §456.057 Fla. Stat. [statute]; Ensuring compliance with the record keeping and adverse incident reporting requirements of applicable law; Assuming the administrative authority, responsibility, and accountability of implementing our medical services, policies and procedures; Coordinating medical care, maintain effective liaison with attending physicians, and implement methods to keep the quality of care under constant surveillance; Participating in the development of written policies, rules, and regulations to govern the nursing care and related medical and other health services provided by Facility. Medical Director is responsible for seeing that these policies reflect an awareness of and have provisions for meeting the total needs of the residents; Ensuring that residents of the facility receive adequate services appropriate to their needs; Ensuring that the medical regimen is incorporated in the resident care plan; Participating in clinical meetings, which include meetings such as infection control, pharmaceutical services, resident care policies, quality assurance, etc.; Assisting in the development and implementation of written resident care policies and procedures; Developing and participate in in-service training programs for nursing service, and other related services; Attending and participating in resident assessment and care planning meetings as necessary; Serving on the following committees: pharmaceutical services; infection control; quality assessment and assurance committee; utilization review; discharge planning; assessment and care planning committee; and others as necessary or appropriate; Reviewing written reports of surveys and inspections and making recommendations to Facility; Providing continuous services to facility during the term of this agreement and, in accordance therewith; arranging to provide the services of another licensed physician during any absence, vacation, periods of illness, or limited period when Physician is not available; Maintaining the confidentiality of resident information as established by Facilities policies and procedures; Staying abreast of all other responsibilities required of a Medical Director as set forth in any federal or state laws, statutes or regulations as an acted or as may be enacted or amended; Following the duties and responsibilities outlined in the Medical Director job description and Facilities established policies and procedures. Review of the Licensed Practical Nurse/Registered Nurse's job description read, Purpose of Your Job Position: The primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day to day nursing activities performed by CNA/PCAs [Certified Nursing Assistants/Patient Care Assistants] and other nursing personnel. To monitor the performance of CNAs/PCAs, nursing, and non-licensed personnel, provide education and counseling, perform disciplinary action as necessary, and complete performance evaluations. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. Participate in the maintenance and implementation of the Facility's quality assurance program for the Nursing Services Department. Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Review of the Unit Supervisor's job description read, Purpose of Your Job Position: The primary purpose of your position is to assist the Director of Nursing Services in planning, organizing, developing and directing the day to day functions of the nursing service department in accordance with current federal, state, and local standards guidelines, and regulations that govern the Facility, and as may be directed by the Administrator, the Medical Director, and/or Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times. Participate in the maintenance and implementation of the Facility's quality assurance program for the Nursing Services Department. Monitor the Facility's QI/QM, and survey reports and provide the Director of Nursing Services with recommendations that will be helpful in eliminating problem areas. Review of Resident #1's physician order dated [DATE] at 1:46 PM read, Perform Accuchek [testing of blood glucose] before meals and at bedtime related to Type 2 Diabetes Mellitus with foot ulcer. Review of Resident #1's physician order dated [DATE] at 6:41 PM read, Glucagon Emergency Injection Kit 1 MG [milligram] [glucagon emergency injecton], Inject 1 application subcutaneously as needed for Administer [Sic.] if BS [blood sugar] <60 [less than 60] recheck sugar Q2H [every 2 hours]. Review of Resident #1's progress note dated [DATE] at 12:45 AM read, Received with low blood sugar rechecked with a 72 result [American Diabetes Association recommended blood sugar range for adult with Type II Diabetes is 80 to 130] . responsive with eyes and asked if he wants to go to ER [Emergency Room] and he shook head no, oral [glucose] gel [used for people with diabetes to raise their blood sugar levels] received and able to swallow. Review of the 5-Day Entry Minimum Data Set, dated [DATE] read, BIMS 14 [Brief Interview for Mental Status - cognition is considered intact]. Review of Resident #1's physician orders for [DATE] did not provide documentation of an order for glucose gel. Review of Resident #1's Medication Administration Record for the period of [DATE] through [DATE] documented blood sugar values between 80 and 220. Review of Resident #1's nursing progress notes for [DATE] did not provide documentation of Resident #1's physician being notified of Resident #1's blood sugar value and the administration of glucose gel. Review of Resident #1's progress note dated [DATE] at 1:49 AM read, Less responsive. Review of Resident #1's progress note dated [DATE] at 3:00 AM read, Monitoring blood sugar with results of 42, unstable blood sugar. On call MD [Medical Doctor covering for Medical Doctor #1] contacted with report of cond. [condition] orders to give the glucagon at this time IM [intramuscular]. Review of Resident #1's Medication Administration Record for the month of [DATE] documented Glucagon Emergency Kit 1 mg was administered on [DATE] at 3:12 AM. Review of Resident #1's progress note dated [DATE] at 3:50 AM read, Glucagon given SQ [subcutaneous] to left arm per order of the on call for [Medical Doctor #1's name, Advanced Practice Registered Nurse (APRN)#1's name], monitor and send to ER if no positive response to Glucagon. Review of Resident #1's progress note dated [DATE] at 6:15 AM read, INC [incontinent] of large amount of loose stool, BS rechecked x 2 [times two] 50 result at 0530 [5:30 AM], not responding to verbal or physical stimuli, rechecked blood sugar 0630 [6:30 AM] with result of 32 (Normal blood sugar values are between 70-99, a value of 32 is considered hypoglycemia, a dangerous condition that requires immediate medical attention). 911 notified of ER [Sic.] with response team arriving at 0630. After evaluation of team sent to ER. Review of Resident #1's physician order dated [DATE] at 7:00 AM read, Send to ER for hypoglycemia without response to Glucagon tx [treatment]. Review of Resident #1's progress note dated [DATE] at 10:07 PM read, Resident expired at the hospital 4/9. During a telephonic interview on [DATE] at 10:10 PM, Staff A, Licensed Practical Nurse (LPN), stated, I do remember [Resident #1's name]. At the beginning of my shift [11:00 PM - 7:00 AM], I checked him, he was awake, alert, taking juice and took the glucose gel. I checked his blood sugar, but I do not think I charted the blood glucose. His level would go up and then go back down. When I called the on-call provider for [Medical Doctor #1's name], she said her name was [First Name of APRN #1] and I asked if he should go to the ER and she [APRN #1] said to give him Glucagon. When I checked his [Resident #1's] blood glucose afterward it went up, I went back to check on him at end of shift and that is when his blood glucose had dropped, and I called 911. During an interview on [DATE] at 11:45 AM, the Director of Nursing (DON) stated, We review 100% of all transfers to acute care facilities. QI [Quality Improvement] tool utilized for review of acute care transfers. We check care that was provided 72 hours prior to transfer to determine if there are any opportunities for improvement and to identify if there are any reportable events. The reviews are conducted by the two nurse managers and myself. The nurse managers generally review the charts for residents that were transferred from their units to an acute care facility. [Resident #1's name] was not identified to be a Federal or State reported event because record review did not identify any areas in need of improvement at the time of review and there were no complaints received about this resident. I am trying to get nursing to complete the interact SBAR [Situation, Background, Assessment, and Recommendation] anytime there is a change in condition. During an interview on [DATE] at approximately 12:00 PM, Staff C, LPN, Unit Manager, confirmed that she had conducted the chart review for Resident #1 and stated The nurse followed the physician order. The order stated to check the blood sugar Q [every] 2 hours after Glucagon was given. During an interview on [DATE] at 7:25 AM, Staff A, LPN, stated, I did check the resident's [Resident #1's] blood sugar more often than is documented. At least every 30 minutes. Record review on [DATE] at 9:45 AM of Staff A, LPN's competency documentation confirmed Staff A did not include education about glucagon in February 2025 and review of Staff A's competency file did not have education documentation regarding glucagon. During an interview on [DATE] at approximately 7:55 AM, the DON stated, Nurses should follow the physician orders and if Glucagon is ordered, they should check the BS in 30 minutes. I know why [Staff A's name] said 30 minutes because the orders are usually written to recheck in 30 minutes not Q2 hours. We have a policy, but it does not include the use of glucagon. When asked regarding the quality review of Resident #1's return to the hospital and the findings, the DON stated, There was documentation issues and post administration blood sugars were not documented. Blood sugar levels that were taken should have been documented and a blood sugar should have been taken 15 minutes after glucagon administration. During a telephonic interview on [DATE] at 9:17 AM, the Medical Doctor #1 stated, My expectation is that the professional standards for management of hypoglycemia should be followed which includes administration of emergency Glucagon, rechecking blood glucose in 15 minutes and reassessing the resident. The physician should be notified of the condition change and if life threatening contact emergency management services for transport to the hospital. During a telephonic interview on [DATE] at 9:30 AM, the Medical Director stated, I expect that professional standards of practice should be followed. After Glucagon administration, the blood sugar should be checked in 15 minutes. I would not order blood sugar to be checked every two hours. If the resident is not responding, emergency management services should be contacted for transport to the hospital. During a telephonic interview on [DATE] at 9:50 AM, the APRN #1 stated, It is my expectation that professional standards of practice should be followed by nursing when a resident is hypoglycemic. I give an order for glucagon and to recheck the blood sugar in 15 minutes and to call me back. During an interview on [DATE] at 12:00 PM, when asked if a change in condition was identified during record review for Resident #1, the DON stated, On [DATE], I requested that the LPN provide me a timeline of what happened. What was found is there were documentation issues. I was not at the last QAPI [Quality Assurance Performance Improvement] meeting held on [DATE]. I will be taking this issue to QAPI on [DATE]. There is no Performance Improvement Plan. During an interview on [DATE] at 12:08 PM, the Administrator stated, I cannot recall when the DON informed me about this Resident [Resident #1]. We talk all the time, but I cannot tell you the exact date and time. During a telephonic interview on [DATE] at 1:50 PM, the Medical Director stated, If a resident has a blood sugar of 32, I will give [glucagon injection] immediately and if symptomatic, I would send them out to the emergency room immediately. Low blood sugar causes circulatory depression, fogginess, and a change in mental condition. The resident diagnoses need to be considered. Many medications are secreted in the kidneys. The resident would need to have intravenous drip and lab work. I did not know about this patient until yesterday [[DATE]]. The facility submitted an acceptable Immediate Jeopardy removal plan with the removal date of [DATE]. The survey team verified the implementation of the facility's immediate actions to remove the immediate jeopardy to include: On [DATE], the DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders for the last 30 days including administration of hypoglycemia interventions with documentation of repeat blood sugars. On [DATE], the DON/designee completed a review of residents who return to the hospital over the past 30 days to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out. On [DATE], the DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered. On [DATE], an Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis. On [DATE], Staff A, LPN, received one on one education on hypoglycemia/hyperglycemia protocol, and change in condition. On [DATE], the facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated. By [DATE], 32 out of 33 licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated. On [DATE], VPCS (Vice President of Clinical Services) reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions. Beginning [DATE], the Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and 24/72 hour report review during clinical standup and stand down meeting, and maintaining QA/PI (Quality Assurance/Performance Improvement) process. Review of the audits showed all active residents in the facility with orders for blood sugar monitoring and insulin administration (32) was reviewed to identify concerns related to insulin administration with the physician orders for the last 30 days with no concerns identified. Review of the audits showed 44 residents were reviewed for changes in condition related to possible hypoglycemia, change in condition, validation of physician notification, physician orders, and implementation of orders over the last 30 days with no concerns identified. During staff interviews conducted on [DATE], seven LPNs and two RNs verified receiving the training and verbalized understanding of diabetes management, policy and procedure on change in condition, anti-hypoglycemia administration and interventions, notification of the DON/ADON when hypoglycemic interventions initiated, documentation of results, and following up with the physician. During interviews conducted on [DATE], the Administrator and the Director of Nursing confirmed receiving training regarding QAPI, identifying issues to bring to QAPI, job responsibilities, failure to identify a concern, change in condition, documentation, the new systems put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, identify, develop, and implement an effective performance improvement plan (PIP) for failure to notify the physician of a resident change in condition and to follow physician's orders. On [DATE] at 12:45 AM, Resident #1 had a blood sugar value of 72, Staff A, Licensed Practical Nurse (LPN), did not contact the provider and administered glucose gel without a physician's order. On [DATE] at 1:49 AM, Resident #1 was less responsive. On [DATE] at 3:00 AM, Resident #1 had a blood sugar value of 42. The on-call physician was called, and ordered to administer Glucagon intramuscularly, monitor, and send to the emergency room if no positive response to Glucagon received. On [DATE] at 5:30 AM, Resident #1 had a blood sugar value of 50. The blood sugar value was rechecked with a blood sugar value of 50. Resident #1 was not responding to verbal or physical stimuli. The provider was not notified, Glucagon was not administered per physician's order when blood sugar dropped below 60 for a second time, and the resident was not sent out to the emergency room per the physician's order. On [DATE] at 6:30 AM, Resident #1 had a blood sugar value of 32. Glucagon was not administered per the physician's order. Emergency Medical Services, 911, were called and Resident #1 was transported to a local hospital. Resident #1 did not survive. This failure places all 118 current residents who may possibly suffer a change in condition at risk. The facility's failure to implement the policies and procedures for change in condition, notifying the physician of a change in condition, and not following physician's orders led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:15 PM. Findings include: Review of the facility policy and procedure titled Quality Assurance and Performance Improvement (QAPI) program with the last review date of [DATE] read, Policy: It will be the policy of this facility that the facility, including a facility that is part of a multiunit chain, will develop, implement, and maintain an effective, comprehensive, data-drive QAPI program that focuses on indicators of the outcomes of care and quality of life. Review of the facility policy and procedure titled QAPI Program Systemic Analysis and Systemic Action with the last review date of [DATE] read, Policy: The facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. Procedure: 1. The facility will utilize a systemic approach to determine underlying causes of problems impacting larger systems. This may include, but not be limited to, any one or more of the following: a. group discussion (Brainstorming), b. application of practical experience with similar problems (Case Based Reasoning), c. root cause analysis, d. identification and description of the problem, e. establishing a sequence of events, f. causal factors differentiation, g. causal graphing, h. other method(s) for determining underlying causes. 2. The facility will develop corrective actions that will be designed to effect change at the system level to prevent quality of care, quality of life, or safety problems. During an interview on [DATE] at 11:45 AM, the Director of Nursing (DON) stated, We review 100% of all transfers to acute care facilities. QI [Quality Improvement] tool utilized for review of acute care transfers. We check care that was provided 72 hours prior to transfer to determine if there are any opportunities for improvement and to identify if there are any reportable events. The reviews are conducted by the two nurse managers and myself. The nurse managers generally review the charts for residents that were transferred from their units to an acute care facility. [Resident #1's name] was not identified to be a Federal or State reported event because record review did not identify any areas in need of improvement at the time of review and there were no complaints received about this resident. I am trying to get nursing to complete the interact SBAR [Situation, Background, Assessment, and Recommendation] anytime there is a change in condition. During an interview on [DATE] at approximately 12:00 PM, Staff C, LPN, Unit Manager, confirmed that she had conducted the chart review for Resident #1 and stated The nurse followed the physician order. The order stated to check the blood sugar Q [every] 2 hours after Glucagon was given. During an interview on [DATE] at approximately 7:55 AM, the DON stated, Nurses should follow the physician orders and if Glucagon is ordered, they should check the BS in 30 minutes. I know why [Staff A's name] said 30 minutes because the orders are usually written to recheck in 30 minutes not Q2 hours. We have a policy, but it does not include the use of glucagon. When asked regarding the quality review of Resident #1's return to the hospital and the findings, the DON stated, There was documentation issues and post administration blood sugars were not documented. Blood sugar levels that were taken should have been documented and a blood sugar should have been taken 15 minutes after glucagon administration. During a telephonic interview on [DATE] at 9:17 AM, the Medical Doctor #1 stated, My expectation is that the professional standards for management of hypoglycemia should be followed which includes administration of emergency Glucagon, rechecking blood glucose in 15 minutes and reassessing the resident. The physician should be notified of the condition change and if life threatening contact emergency management services for transport to the hospital. During a telephonic interview on [DATE] at 9:30 AM, the Medical Director stated, I expect that professional standards of practice should be followed. After Glucagon administration, the blood sugar should be checked in 15 minutes. I would not order blood sugar to be checked every two hours. If the resident is not responding, emergency management services should be contacted for transport to the hospital. During a telephonic interview on [DATE] at 9:50 AM, the APRN #1 stated, It is my expectation that professional standards of practice should be followed by nursing when a resident is hypoglycemic. I give an order for glucagon and to recheck the blood sugar in 15 minutes and to call me back. During an interview on [DATE] at 12:00 PM, when asked if a change in condition was identified during record review for Resident #1, the DON stated, On [DATE], I requested that the LPN provide me a timeline of what happened. What was found is there were documentation issues. I was not at the last QAPI [Quality Assurance Performance Improvement] meeting held on [DATE]. I will be taking this issue to QAPI on [DATE]. There is no Performance Improvement Plan. During an interview on [DATE] at 12:08 PM, the Administrator stated, I cannot recall when the DON informed me about this Resident [Resident #1]. We talk all the time, but I cannot tell you the exact date and time. During a telephonic interview on [DATE] at 1:50 PM, the Medical Director stated, If a resident has a blood sugar of 32, I will give [glucagon injection] immediately and if symptomatic, I would send them out to the emergency room immediately. Low blood sugar causes circulatory depression, fogginess, and a change in mental condition. The resident diagnoses need to be considered. Many medications are secreted in the kidneys. The resident would need to have intravenous drip and lab work. I did not know about this patient until yesterday [[DATE]]. Review of Resident #1's physician order dated [DATE] at 1:46 PM read, Perform Accuchek [testing of blood glucose] before meals and at bedtime related to Type 2 Diabetes Mellitus with foot ulcer. Review of Resident #1's physician order dated [DATE] at 6:41 PM read, Glucagon Emergency Injection Kit 1 MG [milligram] [glucagon emergency injection], Inject 1 application subcutaneously as needed for Administer [Sic.] if BS [blood sugar] <60 [less than 60] recheck sugar Q2H [every 2 hours]. Review of Resident #1's progress note dated [DATE] at 12:45 AM read, Received with low blood sugar rechecked with a 72 result [American Diabetes Association recommended blood sugar range for adult with Type II Diabetes is 80 to 130] . responsive with eyes and asked if he wants to go to ER [Emergency Room] and he shook head no, oral [glucose] gel [used for people with diabetes to raise their blood sugar levels] received and able to swallow. Review of the 5-Day Entry Minimum Data Set, dated [DATE] read, BIMS 14 [Brief Interview for Mental Status - cognition is considered intact]. Review of Resident #1's physician orders for [DATE] did not provide documentation of an order for glucose gel. Review of Resident #1's Medication Administration Record for the period of [DATE] through [DATE] documented blood sugar values between 80 and 220. Review of Resident #1's nursing progress notes for [DATE] did not provide documentation of Resident #1's physician being notified of Resident #1's blood sugar value and the administration of glucose gel. Review of Resident #1's progress note dated [DATE] at 1:49 AM read, Less responsive. Review of Resident #1's progress note dated [DATE] at 3:00 AM read, Monitoring blood sugar with results of 42, unstable blood sugar. On call MD [Medical Doctor covering for Medical Doctor #1] contacted with report of cond. [condition] orders to give the glucagon at this time IM [intramuscular]. Review of Resident #1's Medication Administration Record for the month of [DATE] documented Glucagon Emergency Kit 1 mg was administered on [DATE] at 3:12 AM. Review of Resident #1's progress note dated [DATE] at 3:50 AM read, Glucagon given SQ [subcutaneous] to left arm per order of the on call for [Medical Doctor #1's name, Advanced Practice Registered Nurse (APRN)#1's name], monitor and send to ER if no positive response to Glucagon. Review of Resident #1's progress note dated [DATE] at 6:15 AM read, INC [incontinent] of large amount of loose stool, BS rechecked x 2 [times two] 50 result at 0530 [5:30 AM], not responding to verbal or physical stimuli, rechecked blood sugar 0630 [6:30 AM] with result of 32 [Normal blood sugar values are between 70-99, a value of 32 is considered hypoglycemia, a dangerous condition that requires immediate medical attention]. 911 notified of ER [Sic.] with response team arriving at 0630. After evaluation of team sent to ER. Review of Resident #1's physician order dated [DATE] at 7:00 AM read, Send to ER for hypoglycemia without response to Glucagon tx [treatment]. Review of Resident #1's progress note dated [DATE] at 10:07 PM read, Resident expired at the hospital 4/9. Review of the Administrator's job description acknowledged on [DATE], read, Purpose of Your Job Position: The primary purpose of your position is to direct the day to day functions of the Facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to all our residents at all times . Duties and Responsibilities . Committee Functions . Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Review of the Director of Nursing's job description acknowledged on [DATE], read, Purpose of Your Job Position: The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times . Duties and Responsibilities. Administrative Functions . Develop, implement, and maintain an ongoing quality assurance program for nursing service department . Monitor the Facility's QI, QM [Quality Improvement/Quality Management] and survey reports. Assist in developing plans of action to correct potential or identified problem areas. Review of the Assistant Director of Nursing Service's job description acknowledged on [DATE] read, Purpose of Your Job Position: The primary purpose of your position is to assist the Director of Nursing Services in planning, organizing, developing, and directing the day to day function of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our Facility, and as may be directed by Administrator, the Medical Director, and/or the Director of Nursing Services to ensure that highest degree of quality care is maintained at all times. Delegation of Authority: As Assistant Director of Nursing Services you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In absence of the Director of Nursing Services, you are charged with carrying out the resident care policies established by this Facility. Duties and Responsibilities. Administrative Functions . Monitor the Facility's QI/QM and survey reports and provide the Director with recommendations that will be helpful in eliminating problem areas . Committee Functions . Serve on the Quality Assurance and Assessment Committee, as directed. Review of the Medical Director's Agreement read, Performance Requirements and Duties and Responsibilities of a Nursing Facility Medial Director. Exhibit A: 'Medical Director Services' - agreement in writing to accept legal responsibility for those activities of the facility pursuant to §400.9935 Florida statutes . Serving on the following committees: pharmaceutical services; infection control; quality assessment and assurance committee; utilization review; discharge planning; assessment and care planning committee; and others as necessary or appropriate. Review of the Licensed Practical Nurse/Registered Nurse's job description read, Purpose of Your Job Position: The primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day to day nursing activities performed by CNA/PCAs [Certified Nursing Assistants/Patient Care Assistants] and other nursing personnel . Participate in the maintenance and implementation of the Facility's quality assurance program for the Nursing Services Department. Review of the Unit Supervisor's job description read, Purpose of Your Job Position: The primary purpose of your position is to assist the Director of Nursing Services in planning, organizing, developing and directing the day to day functions of the nursing service department in accordance with current federal, state, and local standards guidelines, and regulations that govern the Facility, and as may be directed by the Administrator, the Medical Director, and/or Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times. Participate in the maintenance and implementation of the Facility's quality assurance program for the Nursing Services Department. Monitor the Facility's QI/QM, and survey reports and provide the Director of Nursing Services with recommendations that will be helpful in eliminating problem areas. The facility submitted an acceptable Immediate Jeopardy removal plan with the removal date of [DATE]. The survey team verified the implementation of the facility's immediate actions to remove the immediate jeopardy to include: On [DATE], the DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders for the last 30 days including administration of hypoglycemia interventions with documentation of repeat blood sugars. On [DATE], the DON/designee completed a review of residents who return to the hospital over the past 30 days to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out. On [DATE], the DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered. On [DATE], an Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis. On [DATE], Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition. On [DATE], the facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated. By [DATE], 32 out of 33 licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated. On [DATE], VPCS (Vice President of Clinical Services) reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions and 5 elements of QAPI, root cause analysis, QAPI at a glance, and QAPI self-assessment tool. Beginning [DATE], the Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and 24/72 hour report review during clinical standup and stand down meeting, and maintaining QA/PI (Quality Assurance/Performance Improvement) process. On [DATE], an Ad Hoc QAPI meeting was convened to review the components of ongoing PIP and review the findings of F867 QAPI/QAA. Review of the audits showed all active residents in the facility with orders for blood sugar monitoring and insulin administration (32) was reviewed to identify concerns related to insulin administration with the physician orders for the last 30 days with no concerns identified. Review of the audits showed 44 residents were reviewed for changes in condition related to possible hypoglycemia, change in condition, validation of physician notification, physician orders, and implementation of orders over the last 30 days with no concerns identified. During staff interviews conducted on [DATE], seven LPNs and two RNs verified receiving the training and verbalized understanding of diabetes management, policy and procedure on change in condition, anti-hypoglycemia administration and interventions, notification of the DON/ADON when hypoglycemic interventions initiated, documentation of results, and following up with the physician. During interviews conducted on [DATE], the Administrator and the Director of Nursing confirmed receiving training regarding QAPI, identifying issues to bring to QAPI, job responsibilities, failure to identify a concern, change in condition, documentation, the new systems put in place.