**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and medical professional interviews the facility failed to promptly identify and intervene for an acute change in a resident's condition related to dehydration for 1 of 3 residents reviewed (Resident#2), resulting in Resident #2 being transported and admitted to the hospital via ambulance 10/22/24 with severe dehydration and sepsis. Resident #2 died on [DATE]. Resident #2's Electronic Health Record (EHR) documented he had acute changes in condition noted as follows with lack of follow up assessments and notification to the physician with the condition changes: 10/17/24 increased blood pressure 10/18/24 No assessment completed 10/19/24 slightly elevated pulse 10/20/24 increase in pulse, blood pressure and mental status change. 10/21/24 No assessment completed 10/22/24 prior to being seen by psych via telecare in the early afternoon no assessment completed. On 12/03/24 at 4:45 PM, the Iowa Department of Inspections, Appeals, and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. This Immediate Jeopardy situation started on 10/17/24, the day Resident #2's documentation noted an acute change in condition with no physician notification and no follow up assessment completed. The facility staff removed the immediacy on 12/4/24 after the facility staff completed the following: Corrective Action: a. Immediate in-service for nurses on identifying acute changes in resident conditions, conducting complete assessments, and notification of providers of changes in condition in a timely manner. b. Attestation of these procedures for all shifts prior to caring for the residents c. Immediate review of all resident documentation going back 72 hours to ensure there were no current changes of condition that may require follow-up, further assessment, or provider notification. d. Any identified concerns will be assessed and the proper notifications made prior to clinical leadership leaving for the day. e. Started Daily auditing of all resident records to ensure that there are no current changes of condition that may require follow-up, further assessment, or provider notification. The scope lowered from a J to G (harm that is not immediate) on 12/04/24 after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had moderate impaired cognition. The MDS further revealed during the 7 day look back period he had not exhibited any rejection of care. The MDS documented he needed Supervision or touch assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating. The MDS documented diagnoses of diabetes, hip fracture, Alzheimer's disease and hypertension. Resident #2's Care Plan with a focus for potential for unplanned weight changes related to variable oral intake of meals and fluids, diabetes mellitus, Alzheimer's Disease with confusion, history of hip fracture and hospitalization. The interventions for the focus were to provide and serve diet as ordered, he needs assistance with feeding, and weight weekly and as needed. Review of the EHR for Resident #2 documented the following: Resident #2's discharge summary from the hospital on [DATE] documented he was initially taken to the local ER where imaging revealed a right displaced femur fracture. He had a hip replacement on that side in 2022. Workup aside from hip fracture was unremarkable aside from mild thrombocytopenia. The resident was medically stable for discharge. Review of the skilled assessments documented the following findings: 10/17/24 increased blood pressure with no follow up or notification to the physician. 10/18/24 No assessment completed that 24 hour time period last completed on 5:27 AM on 10/17/24. 10/19/24 slightly elevated pulse with no follow up or notification to the physician. 10/20/24 increase in pulse, blood pressure, and mental status change. with no follow up or notification to the physician. 10/21/24 No assessment completed since assessment completed since 10:42 AM on 10/20/24 10/22/24 prior to being seen by psych provider via telecare in the early afternoon no assessment completed. Review of Resident #2's Progress Notes document the following: 10/20/24 10:38 PM : The resident was sleepy during supper. It is noted that resident is pocketing food, Licensed Practical Nurse (LPN) attempted to offer resident Ensure and it ran out of resident's mouth. Pain medication and other medications were administered prior to supper with no issues. We will continue to monitor. 10/21/24 6:35 PM : The resident returned, from supper, clammy, not very active, eyes closed, drooling. The resident had been like this at the start of shift although not clammy until after supper. vitals taken, BS 196. afebrile. was reported that he attempted to hit the Certified Nursing Assistant (CNA) as she was trying to feed him. Will continue to monitor him. 10/21/24 7:05 PM CNA's alerted this nurse to bloody drainage noted on sweatpants, when laying resident in bed, right side along the incision site. This nurse did not see any openings along the incision, no fluids were noted after palpating the incision area. Drainage is a serosanguinous (watery fluid and blood), moderate amount. Positioned resident on the right side, pillow between his legs to keep hip aligned. 10/22/24 5:15 AM The resident has a fever of 100.1 Fahrenheit (F), Tramadol was given earlier and at this time cool compress to forehead temp 99.2 F at beginning of shift. 10/22/24 1:32 PM Resident is lethargic, responds to verbal stimuli, when asked a question he is not able to answer, he is noted to be grimacing occasionally, and occasionally makes jerking movements. The writer called the resident's Power of Attorney (POA) with an update and voicemail left on the ARNP's nurse phone. We will continue to monitor. 10/22/24 3:43 PM Resident transferred to ED via ambulance. Review of the Psych Telehealth note written on 10/22/24 documented: Today, staff report Resident #2 has had a change in mental status over the past 24 hours, blood pressure is slightly elevated, and running a low-grade temperature. Resident #2 is brought into a private office for an exam. He appears in distress - grimacing and respirations mildly elevated. He does not open his eyes or engage in conversation. Appointment concluded. Nursing staff instructed to notify PCP immediately as he appears to need urgent medical evaluation. During an interview on 12/02/24 at 2:36 PM Staff A, Registered Nurse (RN) reported for the 10/20/24 change in condition she passed it on in report to the next shift nurse to monitor. She reported at that time she did not notify the physician of changes. She reported she should have. For the change of condition on 10/22/24 she left a voicemail on the Advanced Nurse Practitioner's nurse phone on the condition change at 1 PM. She reported she then got a call back at 2:55 PM that recommended sending to the ED if the family was okay. She called the Power of Attorney and she didn't answer so called the second emergency contact which is a daughter and she wanted him sent to the ED. She then called the ambulance and the resident was sent out. During an interview on 12/02/24 at 10:20 AM, the Nurse Consultant reported the Nurse Practitioner reported she was not aware of any condition change or concerns with Resident #2 until 10/22/24 when the nurse called after he was seen by Psych. She reviewed the chart and no one was notified in the office. He reported staff should have notified the physician or the Nurse Practitioner. During an interview on 12/03/24 at 12:52 PM the Psychiatric-Mental Health Nurse Practitioner (PMHNP) reported she had been following Resident #2 for a year and a half via telehealth (the use of digital technology to access health care services remotely via video) for psych care and so she knows the resident. She reported on his appointment on 10/22/24 he was slumped over and not responding to her questions like he normally would. He would answer yes/no questions in the past. She noted he had been grimacing and respirations were mildly elevated. She noted the mental status change and staff reported he had this change for 24 hours, that he was running a low-grade fever and that his blood pressure was slightly evaluated. She immediately stopped the visit and told the nurse to notify his primary care physician and as he appeared to need urgent medical evaluation. During an interview on 12/03/24 at 3:55 PM Resident #2's Advanced Registered Nurse Practitioner (ARNP) reported her and her office were not aware of any change in condition prior to the notification on the afternoon of 10/22/24. Resident #2's emergency room (ED) Notes dated 10/22/24 at 4:14 PM: Resident #2 with significant dementia and a recent right femur surgical repair on 10/11 who is a resident at [NAME] home. Presents today from the nursing home with fever, tachycardia (elevated heart rate), and decreased responsiveness. History is per nursing staff who spoke with nursing home staff as well as Emergency Medical Staff providers. Staff report he started to have a fever today which was controlled with Tylenol. They report his mental state has not been the same since he was hospitalized for his femur fracture. He appears profoundly dehydrated in the bed, dry mucus membranes and dry skin, and opens his eyes to voice. He is not verbally responsive. IV was established by EMS and Normal Saline was started. admitted with sepsis and dehydration. Hospital Physician Progress Note dated 10/25/24 documented Resident #2 discharged from the hospital on October 14 after sustaining a femur fracture and Sodium level was 143 upon discharge. He was transferred to the nursing home after discharge from the hospital. - Per chart review, it was noted that Resident #2 was having mental status changes, fever, and minimal urine output with possible 1 episode of urination per shift for a week prior to this admission. Nurse Practitioner documented conversation on October 22 he was admitted on [DATE] with a 7 Liter water deficit. Resident #2's Progress Notes documented the following: 10/29/24 11:11 AM The resident returned from hospital stay. 10/29/24 11:31 AM The resident admitted to hospice level of care. 11/07/24 12:29 AM The resident passed. Resident #2's Death Record documented immediate cause of death was dehydration due to or as a consequence of sepsis.

Based on observations, clinical record review, staff interview, family interview, physician interview, the director of the emergency room interview, and facility policy review, the facility failed to assure that staff provided appropriate assessments and interventions for one (1) resident who presented with a high blood sugar (Resident #1). This failure resulted in the resident having a significant change of condition, a trip to the emergency room (ED) for treatment, and an attempted stabilization of condition. The ambulance crew then attempted to transfer the resident to a larger hospital when he suffered a cardiac arrest (heart beat stopped) in the ambulance and passed away, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of June 29, 2023. The Facility Staff removed the Immediate Jeopardy on June 20, 2023 through the following actions: a. Assurance that all necessary future facility staff and agency had been educated on the updated Blood Glucose Policy, the new policy document (Finger Stick Blood Glucose Policy, 6/11/23) would have been included within the human resources new hire orientation packets for the appropriate staff (certified medication aides (CMA) and (&) licensed nurses). b. Assurance that all necessary future facility staff and agency staff were educated on the updated Resident Change of Condition, Assessment & Intervention Policy, the new policy document (Resident Change of Condition, Assessment & Intervention, 6/29/23) would have been included within the human resources new hire orientation packets for the appropriate staff (CMA's & licensed nurses). The scope lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 57 residents. Findings Include: A State of Iowa, Iowa Department of Public Health Certificate of Death for Resident #1 indicated the cause of death as systemic sepsis, etiology unknown with cardiovascular collapse. Other significant conditions included type II diabetes mellitus with hyperosmolar/hyperglycemic state, coronary artery disease, chronic diastolic heart failure, dementia, history of right hemispheric CVA (cerebral vascular accident), peripheral vascular disease with bilateral below the knee amputation, chronic kidney disease, and smoking. A Minimum Data Set (MDS) assessment form dated 3.15.23 indicated Resident #1 had diagnoses that included a non traumatic brain dysfunction, diabetes mellitus (DM), anemia, coronary artery disease (CAD), heart failure (HF), hypertension (HTN), cerebrovascular accident (CVA) and non-Alzheimer's dementia. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (severely impaired cognitive skills), exhibited verbal behavior symptoms one (1) to three (3) days during the look back period (14 days), as non ambulatory, dependent on staff with transfers, locomotion and bathing, required extensive assistance of staff with bed mobility, dressing, eating, personal hygiene and toilet use and as always incontinent of his bowel and bladder. Review of the Resident's Care Plan included the following Focus areas and Interventions as dated: a. The Resident could have been physically aggressive related to (r/t) dementia with behaviors. (revised 1.4.23) b. The resident had a potential for care resistance r/t dementia. (revised 3.7.23) c. The resident had DM. (revised 1.4.23) 1. If an infection presented itself, consult with a physician regarding any changes in diabetic medications. (initiated 1.4.23) 2. Monitor/document and report as needed (PRN) any signs and symptoms of hyperglycemia, increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace), acetone breath (smelled fruity) and slurred speech. (initiated 1.4.23) d. The resident had DM without medication usage. (revised 1.4.23) A Medication Administration Record (MAR) form dated 6.1.23 thru 6.30.23 revealed on 6.8.23 the resident presented with a blood sugar of 495 (a dangerously high level). Record review of the facilities Progress Notes revealed the following entries as dated: a. 6.7.23 at 9:10 p.m. - Resident with a nonproductive cough. Resident also presented with crackles throughout his lung fields. Head of bed (HOB) elevated 45 degrees. Resident afebrile. No further assessment completed. (i.e., vital signs, skin color, shortness of breath and no physician notification. b. 6.8.23 at 4:12 a.m. - Resident rested in bed with HOB elevated. No cough or audible wheeze noted. Temperature (T) 97.9 degrees Fahrenheit (F) and oxygen saturation (O2 sat) at 94% at room air. No further assessment completed and no mention of an elevated blood sugar with the corresponding assessment expected as directed above in the care plan. c. 6.8.23 at 9:21 a.m. - A new order received for Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligrams (mg)/3 milliliters (ml) 0.083% 1 vial orally via a nebulizer every morning (am) and at bedtime (HS) for wheezing and cough and 1 vial every 4 hours PRN for cough and wheezing. No assessment completed throughout the day. A facility report sheet dated 6.8.23 indicated the resident had not felt well on the day and afternoon shift and failed to eat supper. d. 6.9.23 at 1:20 a.m. - HOB elevated, respirations (R) easy with no audible wheeze noted. Soft non-productive cough noted at times. Pain at a 0. No further assessment completed. e. 6.9.23 at 3:41 p.m. - It had been noted the Nurse Practitioner (NP) had been in the facility and had reviewed the recent weight change form. At that time the staff identified a weight gain. The staff called a family member and left a message. At that time staff identified no further concerns. g. 6.9.23 at 9:01 p.m. - When the resident's urine output had been measured staff noted the urine as dark brown in color when they drained 350 milliliters (ml) from his catheter bag. Staff planned to continue to monitor for improvements/worsening of symptoms. No further assessment completed. i. 6.10.23 at 5:50 a.m. - Resident positioned in bed with HOB elevated. Resident with a urine output of 100 ml of dark colored urine. Not cough noted. Staff questioned Resident if his chest felt better following a nebulizer treatment and the resident stated yes. The resident sounded more alert than usual. j. 6.10.23 at 8:22 a.m. - Resident positioned in bed with HOB elevated. Lungs clear to auscultation. No signs and symptoms of distress noted. No cough or complaints of pain. No further assessment completed. k. 6.10.23 at 3:50 p.m. - The nurse checked routine vitals on the resident and noticed his vitals registered as follows: pulse 100, R 36, O2 saturation, when registered at 68%, and T 97.7 degrees F. Resident also continued to have very dark and concentrated urine. The resident's demeanor also appeared altered as he normally had been very vocal and agitated during cares and on that day he had not been. Call placed to NP and family and decision made for transfer to the hospital. A Clinic Note from a NP dated 6.8.23 (no time identified) indicated the resident had been seen for concerns regarding a cough and wheezing. Staff reported his cough and wheezing as significant and caused some discomfort. Staff reported no change in appetite and no increased fatigue. The NP ordered Albuterol Nebs twice a day (BID) and every 4 hours PRN. The NP documented the visit diagnosis as an acute cough. During an interview 6.29.23 at 7:50 a.m. the NP described the communication at the facility along with cares had been really poor. The NP confirmed she had not been told about the resident's high blood sugar on 6.8.23. During an interview 6.29.23 at 10:40 a.m. the NP reported concern for the residents individual safety at the facility because of the facilities failure to staff enough nurses. The NP confirmed she would have expected staff to report the residents high B/S to her for intervention. An Oral Intake form revealed the resident ate the following as dated: a. 6.6.23 at 8:44 a.m. - 51-75% of the meal. 1:07 p.m. - 0-25% 7:41 p.m. - Refused b. 6.7.23 at 8:28 a.m. - 26-50% 12:18 p.m. and 6 p.m. - 0-25% c. 6.8.23 at 9:03 a.m., 12:18 p.m. and 6 p.m. - 0-25% d. 6.9.23 at 9:59 a.m., 12:25 p.m. and 6 p.m. - 0-25% e. 6.10.23 at 8 a.m. - 0-25% A facility Charge Sheet dated 6.9.23 into 6.10.23 on the night shift included documentation that directed staff to have monitored the resident's respiratory and catheter status. A facility Charge Sheet dated 6.10.23 for the 6 a.m. until 2:15 p.m. described the resident as congested, with a cough and O2 sat of 96%, pulse 100 and respirations 22. A facility Charge Sheet dated 6.10.23 on the afternoon/evening shift included the following documentation that pertained to the resident: blood sugar on 6.8.23 had been 495 with one to one staff assistance required. His blood sugar on 6.5.23 registered at 207. Staff documented an O2 sat of 69% and hard to have been obtained, pulse of 100 and respirations 35. Sent to ED at 3:35 p.m. An ambulance report form dated 6.10.23 at 7:26 p.m. indicated the primary diagnosis as diabetic hyperglycemia. Facility staff reported to the ambulance crew upon arrival the patient normally had been very vocal and mildly combative but for the past two (2) days had been very quiet and refused to eat or drink. Staff verbalized concern with the concentration of his urine. Staff had not completed a blood sugar check. An emergency room (ED) Provider Notes form dated 6.10.23 at 4:09 p.m., the resident present with a hyperosmolar hyperglycemic state (life threatening) with the chief complaint described as an altered mental status. The resident's blood glucose level registered at 681. One of the interventions for the ED staff had been administration of insulin. The Final Impression listed the following diagnosis: a. Hyperosmolar hyperglycemic state b. Anemia c. History of a CVA d. Dementia, unspecified dementia severity, unspecified dementia type e. Hyperkalemia f. Pneumonia of the right lung due to an infectious organism. g. Urinary tract infection with hematuria. During an interview 6.29.23 at 11:51 a.m. an ED Director confirmed staff should have notified a provider and received orders for insulin especially since the resident had not been on any diabetic medications. Additionally, staff should have monitored blood sugars and sent the resident to the ED on 6.8.23. The ED Director felt it had been difficult to say if the high blood sugars caused the resident to go into cardiac arrest because he had many co-morbidities plus he was septic when he arrived at the hospital on 6.10.23. During an interview at the same time an ED Physician indicated staff should have called the provider, rechecked the resident's blood sugar, assessed if there had been any reason for the high blood sugar i.e., had he eaten or been sick. If his blood sugars continued high he should have been brought into the hospital. The Physician confirmed the resident's high blood sugar could have been prevented and the provider absolutely notified. During an interview 6.28.23 at 6:16 p.m. Staff F, CMA/CNA confirmed she had been the CMA who took the resident's blood sugar and instantly reported it to Staff B, LPN. Staff F indicated she worked with the girls on the floor that day but she knew Staff B went to see the resident. Staff F stated she honestly had not known what happened because when the next shift arrived Staff B had not been present for report. The staff member described the resident's demeanor at the time of the high blood sugar as normal because he cussed and swore at the girls. The staff member described the facilities protocol when a resident's blood sugar presented high, over 300 it should have had been to report to the charge nurse and she would have expected Staff B to have reported back to her interventions but she never followed through accordingly that day and she should have notified the NP right away. When questioned what should have occurred the staff member stated number 1 the blood sugar should have been rechecked and Physician notified. The staff member knew Staff B notified the NP about the resident's respirations but not the blood sugars. During an interview 7.5.23 at 1:38 p.m. Staff B, LPN confirmed they worked 6.8.23 from 6 until 2:30 p.m. and she had been the only nurse in the building with 3 CMA's. The staff member confirmed she had been aware the resident's blood sugar registered high and stated she reported it to the NP along with his congestion and a sore on his right butt cheek. Staff E, CNA/CMA and Staff F, CNA/CMA had also been present. Staff B indicated that all four people were present in the same area when she reported the blood sugar to the NP. Confirmed she reported to PM nurse, Staff H, LPN/Agency the high blood sugar and that the resident failed to eat breakfast or lunch. Stated she assessed the resident but failed to document the assessment because she had been too busy running to other stations looking for resident medications due to the fact of medication change over that night so residents had missing medications. The staff member indicated she had skilled residents to have been assessed, insulin and blood sugars, and that it had been a lot of work for 1 nurse. Staff B described the resident as fine on her shift and acted normally combative and refused cares. Staff B offered that maybe the NP failed to hear her because of her voice and the fact she had not been normal since the 5th of last month d/t double pneumonia, laryngitis, sinus infection, and an ear infection so maybe the NP had not heard her because she had no voice. During an interview 6.28.23 at 4:49 p.m. Staff E, CNA/CMA confirmed she worked the with the resident on the day shift Thursday and Friday as a CNA and she thought Staff F, CNA/CMA that checked his blood sugar. The staff member described the resident's demeanor as usual. The staff member indicated the resident had been put on nebulizer treatments the day before or something she knew something respiratory had been going on but there was nothing that drew her attention there was something going on with the resident. Staff B indicated when she worked as a CMA and if a resident's blood sugar had been high she would have reported the incident to the charge nurse. The staff member knew Staff F told Staff B about the high blood sugar somewhere along the line and she had been 90% sure NP stood right there but the situation had not seemed like a serious matter at the time. During an interview 6.29.23 at 1:35 p.m. Staff E confirmed the resident's blood sugar as taken before he ate because she fed him and he only took a couple bites and she heard the nurse say the blood sugar registered high but nothing more. During an interview 6.28.23 at 5:01 p.m. Staff G, CNA confirmed she worked Thursday June 8th from 2 p.m. until 10 p.m The staff member stated she knew the resident real well and that night he had been real nice so he was off and he failed to eat much. The staff member further described the resident's normal behavior as hyper and aggressive and that day he was not himself. The staff member indicated she reported the situation to an unknown nurse. During an interview 6.29.23 at 4:17 p.m. Staff H LPN/Agency staff confirmed they worked with the resident on 6.8.23 during the 2 p.m. until 10 p.m. shift but she never received report r/t his high blood sugar rather that he was congested and started on nebulizer treatments. The staff member indicated when she sat and fed him that night she heard his congestion plus he only ate bites of food. Staff H confirmed if a resident presented with a blood sugar of 495 she would have called the NP and wait for guidance due to the fact the resident had no insulin order. The staff member would have also rechecked his blood sugar with a different and clean finger because he had stool on his hands a lot of the time. The staff member confirmed the elevated blood sugar would have been a red flag for her. During an interview 6.29.23 at 6:27 a.m. Staff I, CNA confirmed she worked Thursday night at 10 p.m. and during report they told her the resident had not eaten supper. The staff member stated because he failed to eat supper she tried to wake him up around 12 a.m. on rounds but his breath sounds appeared deep. The staff member reported to Staff J, RN that night the resident failed to wake up with the attempted arousal. During an interview 6.29.23 at 7:23 a.m. Staff J, RN confirmed she worked 10 p.m. until 6 a.m. June 3rd through the 11th. and received report but no one reported to her the resident's high blood sugar on 6.8.23 but in that time period they were concerned with his urine and his breathing. The staff member confirmed all staff should have continued an assessment of his blood sugar status. The staff member confirmed if a resident presented with a blood sugar of 495 she would have called the MD or NP and that staff should have reported the incident off to her. During an interview 6.29.23 at 1:22 p.m. Staff K CNA confirmed she worked 6.9.23 2 p.m. until 10 p.m. The staff member indicated when she worked with the resident that shift she described him as not himself further described as subdued. His urine appeared very dark which she further defined as brown with no sediment and decreased output. The staff member reported the resident had not eaten supper on Wednesday night 6.7.23 and 6.9.23 and when he refused to eat she reported the condition to the charge nurse. During an interview 6.28.23 at 12:42 p.m. Staff A, CNA/CMA stated she knew the resident had a high blood sugar on Thursday because staff checked his blood sugars on Monday and Thursdays. The staff member stated if he had a high blood sugar on Thursday it should have been addressed and reported to the physician. During an interview 6.28.23 at 4:31 p.m. Staff D, LPN described the resident's normal demeanor as aggressive. The staff member stated she had no knowledge the resident had been diabetic. During an interview 7.6.23 at 10:40 a.m. a family member indicated he knew the facility failed to follow procedure because someone from the ED called him and said the resident should have been there two days prior.