**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to immediately notify the physician when there was a change in resident condition and/or a need to alter treatment for five (5) of eighteen (18) sampled residents (Resident #250, Resident #7, Resident #19, Resident #12, and Resident #42). The facility utilized a protocol for Hypoglycemia (low blood glucose) that required staff to notify the resident's physician for blood glucose levels (blood sugar) less than 70. On 08/06/2020, Resident #250's fingerstick blood glucose level was 66 (ADA recommendation range for someone with diabetes: 80-130 mg/dl) at 5:09 PM and was 59 at 8:15 PM. However, the resident's physician was not notified of the resident's low blood glucose level. On 08/07/2020 at 12:26 PM, the resident's blood glucose level was 56. On 08/07/2020 at 5:09 PM, the resident had a blood glucose level of 46. Again the facility failed to notify Resident #250's physician of the low blood glucose level. Approximately, four (4) hours hours later at 9:19 PM, the resident's blood glucose level was 37. The physician was notified and Glucagel (used to treat low blood glucose levels) was ordered orally. Resident #250 requested to be sent to the hospital on [DATE] at 9:30 PM. The facility rechecked Resident #250's blood glucose level and documented the level as being 85 prior to the resident leaving the facility; however, the time was not documented. Review of the ambulance documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level as being 34. The resident was transported to the acute care hospital where he/she required intravenous fluids and medication to maintain his/her blood sugar. Resident #250 was diagnosed with Type 2 Diabetes Mellitus with Hypoglycemia. In addition, the facility failed to notify the resident's physician when Resident #7, Resident #19, Resident #12, and Resident #42 had blood glucose levels less than 70. The facility's failure to notify the resident's physician has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/17/2020 and determined to exist on 08/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726). The facility was notified of the Immediate Jeopardy on 09/17/2020. An acceptable Allegation of Compliance was received on 09/23/2020, which alleged removal of Immediate Jeopardy on 09/22/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 09/22/2020 as alleged, prior to exit on 10/01/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's policy titled, Change of Condition, with a revision date of 11/06/19, revealed the facility would evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay evaluation information to the physician and to document actions. A review of a protocol titled,Hypoglycemia Management Algorithm, with a revision date of 09/01/15, utilized by the facility and developed by the American Diabetes Association, revealed staff were required to notify a resident's physician for blood glucose levels (blood sugar) less than seventy (70). The protocol also revealed if the resident was awake and able to swallow a simple carbohydrate such as juice, regular soda, milk, hard piece of candy, glucose gel, or glucose tablets would be administered. Per the protocol, the blood glucose level would be rechecked after fifteen (15) minutes. The protocol revealed if the blood glucose level was not greater than or equal to seventy (70) the physician would be notified again for further direction. The protocol stated if the blood glucose level was greater than or equal to seventy (70) then a protein or nutrious snack such as yogurt would be administered. 1. A review of Resident #250's closed medical record revealed the facility admitted the resident on 08/05/2020, with diagnoses of Type II Diabetes Mellitus, Hypertension, Malignant Neoplasm of Breast, and Mastectomy with Breast Reconstruction. A review of the Baseline admission Care Plan for Resident #250, undated, revealed the facility identified the resident had a diagnosis of diabetes. The facility developed a goal for the resident not to develop complications. The interventions included to continue medications and blood sugars as ordered. A review of the physician's orders for Resident #250, dated 08/05/2020, revealed the resident had an order for staff to obtain the resident's blood sugar before meals and at bedtime. The resident had physician orders to receive Amaryl four (4) milligrams (mg) daily orally (to lower blood glucose level), Metformin one thousand (1000) mg twice daily orally (to lower blood glucose level), and Januvia one hundred (100) mg daily orally (to lower blood glucose level). A review of Resident #250's Medication Administration Records (MARS), revealed documentation of blood glucose monitoring for Resident #250. On 08/06/2020 at 5:09 PM, the resident had a blood glucose level of 66 and with no evidence the physician was notified; on 08/06/2020 at 8:15 PM, the resident had a documented blood glucose level of 59 with no evidence the physician was notified. On 08/07/2020 at 6:00 AM, there was no evidence blood glucose monitoring was completed. Further review revealed on 08/07/2020 at 5:09 PM, the resident's blood glucose level was 46, with no evidence the physician was notified; on 08/07/2020 at 9:19 PM, the resident had a thirty seven (37) documented blood glucose level. A review of Resident #250's Nurses Notes, revealed no documentation of the resident's physician being notified of low blood glucose levels for the resident, until 08/07/2020 at 2:27 PM, when the resident's physician visited the resident and wrote a physician's order to discontinue administration of Amaryl four (4) mg daily orally (to lower blood glucose level). The next mention of physician notification related to the resident's blood glucose levels was on 08/07/2020 at 9:30 PM. The nurses notes further revealed on 08/07/2020 at 9:30 PM, Resident #1's physician was notified due to the resident having a blood glucose level of thirty seven (37), and a new order was received to administer Glucose Gel (to raise blood glucose level) orally now and to discontinue both Metformin one thousand (1000) mg twice daily orally (to lower blood glucose level) and Januvia one hundred (100) mg daily orally (to lower blood glucose level). The nurse documented when she entered the resident's room to administer the Glucose Gel (to raise blood glucose level), the resident stated he/she wanted to be transferred to the hospital. The nurse documented she had notified the resident's physician and arrangements were made to transfer the resident to the hospital. The nurses's notes revealed the resident's blood glucose level was rechecked after he/she was administered Glucose Gel (to raise blood glucose level). However no time was documented when the blood glucose level was obtained. The results were documented as being 85 and the resident was documented as being lethargic and very difficult to arouse. The nurses notes revealed the ambulance service arrived at the facility on 08/07/2020 at 10:27 PM, and departed from the facility to the hospital on [DATE] at 10:34 PM. A review of the ambulance service documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level as being 34. The ambulance record revealed an intravenous line was obtained and 50% Dextrose 25 mg intravenously (used to increase blood glucose level) was administered. The ambulance record revealed the resident opened his/her eyes and was able to nod answers to questions. The ambulance record revealed a second 50% Dextrose 25 mg intravenously was administered and then the resident was able to speak in sentences and move his/her extremities independently. The ambulance documentation revealed the resident was then transferred to the acute care hospital. A review of the acute care hospital record for Resident #250, revealed the resident arrived at the hospital on [DATE] at 11:35 PM. The hospital medical record revealed the resident received a D5W intravenous drip. On 08/07/2020 at 11:45 PM, a blood glucose level of sixty nine (69) was documented and 50% Dextrose 25 mg was administered intravenously. The acute care hospital record further revealed on 08/08/2020 at 1:45 AM, the resident's blood glucose level was documented as being less than 60 and an additional 50% Dextrose 25 mg was administered. The acute care hospital record revealed the resident was admitted by the acute care hospital on [DATE] at 4:19 AM with a diagnoses of Type 2 Diabetes Mellitus with Hypoglycemia. An interview with Licensed Practical Nurse (LPN) #2, on 09/14/2020 at 6:51 PM, revealed she had helped LPN #3 on 08/07/2020 at 9:19 PM when Resident #250's blood glucose level was 37. The LPN stated she had told LPN #3 to notify Resident #250's physician. LPN #2 stated LPN #3 had administered Glucagel (to raise blood glucose level) and had rechecked the blood glucose level and it was 85. The LPN stated she had assisted LPN #3 with the resident until the resident was sent out of the facility to the acute care hospital. The LPN stated the resident was lethargic. The LPN stated she had not been aware of the Hypoglycemia Management Algorithm. The LPN stated she had only worked at the facility approximately three (3) weeks when the incident occurred. An interview conducted with LPN #3, on 09/15/2020 at 5:45 PM, revealed she was responsible for conducting the blood glucose monitoring, on 08/06/2020 at 8:15 PM, for Resident #250. The LPN stated she was not aware of the Hypoglycemia Management Algorithm on 08/06/2020 and 08/07/2020, when she was responsible for obtaining Resident #250's blood glucose levels. The LPN stated she guessed she should have notified the physician, on 08/06/2020 at 8:15 PM, when Resident #1's blood glucose level was 59. An interview conducted with LPN #7, on 09/16/2020 at 8:46 AM, revealed she had completed the blood glucose monitoring for Resident #250, on the 7:00 AM to 7:00 PM shift on 08/06/2020. The LPN stated on 08/06/2020 at 5:00 PM, the resident's blood glucose level was 66. The LPN stated she had done nothing because she knew resident would be receiving a supper meal tray and the resident had ate well. LPN #7 stated she did not repeat the blood glucose monitoring nor did she notify the physician but should have. The LPN stated she had not been aware of the Hypoglycemia Management Algorithm until after the inservice on 08/11/2020. An interview conducted with Resident #250's Physician, on 09/16/2020 at 10:00 AM, revealed he had been notified and had been aware of Resident #1's blood glucose level on 08/07/2020 at 12:26 PM and on 08/07/2020 at 9:19 PM. The physician stated the facility did not notify him of the resident's blood glucose levels on 08/06/2020 at 5:00 PM of sixty six (66); or the level on 08/06/2020 at 8:15 PM of fifty nine (59); nor of the 08/07/2020 at 5:09 PM, level of forty six (46). The physician stated he should have been notified and would probably have changed the resident's orders. 2. A review of Resident #7's medical record, revealed the facility admitted the resident on 04/10/19, with diagnoses which include Type 2 Diabetes Mellitus, and Stage IV Kidney Disease. A review of Resident #7's physician's orders, revealed an order dated 05/30/2020, for the resident to have blood glucose monitoring before meals and at bedtime. The physicians orders also revealed orders dated 07/08/2020, for the resident to receive Lantus six (6) unit subcutaneous daily (insulin to lower blood glucose level); and Novolin R five (5) units subcutaneous before meals (to lower blood glucose level). A review of Resident #7's current quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a diagnosis of Diabetes Mellitus. The MDS assessment further revealed the resident had received insulin (to lower blood glucose level) injections. A review of Resident #7's comprehensive care plan with a review date of 07/14/2020, revealed interventions were developed to perform blood glucose monitoring as ordered; and to observe for and report signs and symptoms of hypoglycemia. A review of Resident #7's MARS revealed blood glucose monitoring on 08/31/2020 at 4:40 PM at a level of 64; 09/03/2020 at 5:08 PM at a level of 63; on 09/08/2020 at 8:08 PM at a level of 65. Review of the nurse's notes revealed no evidence the resident's physician was notified of the resident's low (less than 70) blood glucose levels on 08/31/2020, 09/03/2020 or 09/08/2020. An interview conducted with Registered Nurse (RN) #2 on 09/16/2020 at 8:20 AM, revealed she had been responsible for performing blood glucose monitoring for Resident #7 on 09/08/2020 at 8:08 PM. The RN stated she had been aware of the Hypoglycemia Management Algorithm, but stated since she felt she could take care of the low level herself, she had not notified the physician and probably should have. An interview conducted with LPN #7 on 09/17/2020 at 10:50 AM, revealed she had been responsible for completing the blood glucose monitoring for Resident #7 on 09/03/2020 at 5:08 PM. The LPN stated she had not notified the physician nor had she repeated the blood glucose monitoring and guessed she probably should have. An interview conducted with LPN #6 on 09/17/2020 at 1:30 PM, revealed she was responsible for completing the blood glucose monitoring on 08/31/2020 at 4:40 PM for Resident #7. The LPN stated she had not repeated the resident's blood glucose monitoring, nor had she notified the resident's physician and should have. 3. A review of the medical record for Resident #19, revealed the resident had been admitted by the facility on 12/17/19, with diagnoses which included Type 2 Diabetes Mellitus, Atrial Fibrillation, and Anxiety. A review of the physician's orders for Resident #19, revealed an order dated 08/24/2020 for the resident to have blood glucose monitoring before meals. Further review revealed an order dated 09/02/2020 for the resident to receive Novolin R Regular U-100 Insulin (to lower blood glucose levels) twelve (12) units subcutaneous after breakfast and after lunch. If the resident does not eat a lot only administer one half the dose; Novolin R Regular U-100 Insulin (to lower blood glucose level) eight (8) units subcutaneous after the evening meal, if the resident does not eat a lot only administer one half the dose. A review of the most current quarterly MDS assessment for Resident #19 dated 08/27/2020, revealed the resident had a diagnosis of Diabetes Mellitus and received insulin (to lower blood glucose levels) injections daily. A review of Resident #19's comprehensive care plan with a revision date of 09/02/2020, revealed interventions had been developed for the resident to receive a Glucagon (to increase blood glucose levels) injection if the resident's blood glucose level was less than 60 and the resident has difficulty responding; provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of hypoglycemia. A review of the MAR for Resident #19, revealed on 09/06/2020 at 5:03 PM, the blood glucose level was documented as being 64 and no insulin (to lower blood glucose level) was administered. There was no evidence the physician was notified or the blood glucose monitoring was repeated. An interview with LPN #9 on 09/17/2020 at 10:40 AM, revealed the LPN was aware of the Hypoglycemia Management Algorithm, and was aware she was required to notify the physician for Resident #19 blood glucose level on 09/06/2020 at 5:03 PM. The LPN stated she did not know why she had not but should have notified the physician. 4. A review of Resident #12's medical record, revealed the facility admitted the resident on 05/13/2020, with diagnoses which include Type 2 Diabetes Mellitus and Chronic Kidney Disease Stage III. A review of the physician's orders for Resident #12, revealed an order dated 05/25/2020, for the resident to receive blood glucose monitoring before meals; and an order dated 06/5/2020, for the resident to receive Novolog U-100 (to lower blood glucose levels) eight (8) units subcutaneous before meals. A review of the most current quarterly MDS assessment for Resident #12 dated 08/12/2020, revealed the resident had a diagnosis of Diabetes Mellitus and received insulin (to lower blood glucose levels) injections daily. A review of Resident #12's comprehensive care plan with a revision date of 08/14/2020, revealed interventions developed to provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of hypoglycemia. A review of the MAR for Resident #12, revealed on 09/03/2020 at 5:13 AM, the blood glucose was documented as being 61; and on 09/09/2020 at 5:22 AM, the blood glucose was documented as being sixty four 64. There was no evidence the physician was notified or the blood glucose monitoring were repeated. An interview conducted with LPN #2 on 09/17/2020 at 10:00 AM, revealed she should have notified Resident #12's physician on 09/03/3030 at 5:13 AM and 09/09/2020 at 5:22 AM when Resident #12 had low blood glucose levels. The LPN stated she was unsure why she had not. The LPN stated she had not been aware of the facility protocol (Hypoglycemia Management Algorithm). 5. A review of Resident #42's medical record, revealed the facility admitted the resident on 09/25/19, with diagnoses which included Type 2 Diabetes Mellitus and Chronic Kidney Disease Stage III. A review of the physician's orders for Resident #42, revealed an order dated 11/04/19, for blood glucose monitoring was to be completed before meals and at bedtime; and an order dated 04/24/2020, for the resident to receive Tresiba U-100 (to lower blood glucose level) one hundred sixty four (164) units subcutaneously every morning. A review of the most current annual MDS assessment for Resident #42 dated 09/08/2020, revealed the resident had a diagnosis of Diabetes Mellitus and received insulin (to lower blood glucose levels) injections daily. A review of Resident #42's comprehensive care plan with a revision date of 09/11/2020, revealed interventions developed to provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of hypoglycemia. A review of the MAR for Resident #42, for 08/20/2020 at 4:40 PM, revealed the blood glucose was documented as being 64; on 08/22/2020 at 4:44 PM, the blood glucose was documented as being 64; on 09/03/2020 at 11:54 AM, the blood glucose was documented as being 57. There was no evidence the physician was notified or the blood glucose monitoring were repeated. An interview conducted with LPN #9 on 09/17/2020 at 10:40 AM, revealed the LPN was aware she was required to notify the physician for Resident #42's low blood glucose levels on 08/20/2020 at 4:40 PM; on 08/22/2020 at 4:44 PM; and on 09/03/2020 at 11:54 AM. The LPN stated she was unsure why she had not. The LPN stated she had not been aware of the Hypoglycemia Management Algorithm. An interview with the Director of Nursing (DON), on 09/17/2020 at 2:30 PM, revealed nurses were required to utilize the Hypoglycemia Management Algorithm anytime a resident had a blood glucose level of 70 or lower. The DON stated if a resident had a blood glucose level of 70 or lower, the resident's physician was required to be notified. The DON stated not notifying the physician for Resident #250's low blood glucose level could have caused the resident harm. Per the DON, she had recently moved to the DON position and was also doing the duties of the Staff Development Nurse and the Infection Control Nurse. The DON stated she had been very busy, due to the additional duties, and had not identified any concerns recently with the physician not being notified of low glucose levels. Interview conducted with the Administrator, on 09/17/2020 at 3:00 PM, revealed staff were required to use the Hypoglycemia Management Algorithm for any resident who had a blood glucose level of 70 or less. The Administrator stated the resident's physician was required to be notified if a resident's blood glucose level was 70 or lower. The facility alleged the following was implemented to remove Immediate Jeopardy on 09/22/2020: 1. Education related to documentation of blood glucose checks, physician notification, and documentation of physician notification related to change in resident's condition was initiated on 08/11/2020, and completed on 08/14/2020 for all licensed nursing staff. 2. Residents at the facility with diagnosis of Diabetes Mellitus were assessed by the Director of Nursing (DON) by 09/18/2020, for signs and symptoms of hyperglycemia/hypoglycemia. No concerns were identified. 3. Residents at the facility with diagnosis of Diabetes Mellitus had charts reviewed by the Signature Care Consultant (SCC), by 09/18/2020. The SCC looked for signs and symptoms of hypo/hyperglycemia for the last 30 days and the treatment plan for hypo/hyperglycemia was followed per physician order. Any issues from chart audits had physician and family notification on 09/21/2020, by the DON or Administrator. No injury or harm was noted. 4. On 09/18/2020, residents with BIMS score of eight (8) or above were asked the following questions by the Social Services Director (SSD) 1): Do the staff address your needs? 2.) If you have a concern or a medical problem, for example a low blood sugar, do the staff respond, notify your doctor and provide treatment if needed? 3.) Do you have any concerns related to your care at this time? No concerns were voiced. 5. On 09/18/2020, residents (with BIMS score of less than eight) families were called and asked the following questions by the SW: 1.) Do you feel the staff address your family members needs appropriately? 2.) If your family member has a change in condition, are you and the physician notified? 3.) Do you have any concerns with your family members care? Any issues were addressed by the Administrator by 09/21/2020. 6. Residents with BIMS of less than eight (8) received an assessment for any signs or symptoms of a change in condition that had not been addressed on 09/18/2020 by the DON and Restorative Nurse. No new concern were noted. 7. The SCC educated the Administrator, DON, MDS Coordinator and the Restorative Nurse on 09/17/2020, regarding the signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, physician and family notification, completing SBAR, Accuchecks, Resident Rights and Abuse/Neglect. 8. All licensed nurses were educated on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, physician and family notification, completing SBAR, Accuchecks, Resident Rights, Abuse/Neglect, and the Hypoglycemia Management Algorithm. The training included appropriate steps to follow such as results received/steps such as management to include simple carbohydrate administration, rechecking of glucose levels and when to notify MD with action to take when new orders were received. This training was initiated by the DON, Restorative Nurse, MDS Coordinator and Administrator, on 09/17/2020. Education would continue prior to staff working their next scheduled shift by 09/21/2020. Licensed Nurse staff who were as needed, on FMLA or on leave would be issued a certified letter by Administrator with return receipt on 09/21/2020, alerting them that they must receive an education on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, completing SBAR and Accucheck competency completed prior to their first shift back to work. A pre-post test would be given in which a passing score of 100% must be obtained on the post test. If 100% not obtained the staff member would be re-educated and a post test would be reissued. 9. All State Registered Nurse Aides (SRNA) and all other facility staff would be provided education on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect was initiated by the DON, MDS Coordinator, Restorative Nurse and Administrator on 09/17/2020. Education would continue prior to staff working their next scheduled shift by 09/21/2020. SRNAs and all other facility staff who are PRN, on FLMA or on leave would be issued a certified letter by Administrator with return receipt on 09/21/2020 alerting them that they must receive education on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect completed prior to their first shift back to work. A pre-post test would be given in which a passing score of 100% must be obtained on the post test. If 100% not obtained the staff member would be re-educated and a post test would be reissued. 10. Accucheck competency would include training on how to perform a glucose check-disinfection process for glucometer, interpretation of glucose results, documentation of glucose results, process for refusal of glucose by resident to include MD notification, and to promptly report abnormal results to the MD and promptly act on any new orders given by physician. This education was performed for Licensed Nurses by the SCC, DON, Restorative Nurse or Administrator beginning on 09/17/2020. Any Licensed Nurses not on duty on 9/17/2020 would receive an accucheck competency, as described above prior to the start of their shift by the DON, Restorative Nurse or Administrator until 100% of Licensed Nurses receive the Accucheck competency. Staff who were PRN, on FLMA or on leave would be issued a certified letter by Administrator with return receipt, on 09/21/2020, alerting them they must receive an education on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, completing SBAR and accucheck competency before being allowed to work their next shift. 11. A QA meeting was held on 09/18/2020 and attended by the Medical Director, Regional [NAME] President (RVP) Administrator, SCC and DON in regards to root cause of event, education, interventions and plans to prevent reoccurrence. 12. Administrator, DON, Restorative Nurse and/or SCC reviewed all grievances for the last 30 days on 09/19/2020 for any other concerns of treatment of Diabetes Mellitus. None were identified. 13. Administrator, DON and SCC reviewed all SBARs and nurse progress notes for the last 30 days starting on 09/18/2020 and completed on 09/21/2020 for any other concerns of treatment of Diabetes Mellitus. None were identified. 14. Beginning 09/19/2020, daily, and until removal of jeopardy, the Administrator (who is a registered nurse) and DON would audit five (5) diabetic residents each shift that reside in the facility to ensure appropriate interventions and appropriate MD notifications has occurred regarding abnormal glucose levels. The Administrator, DON, or Restorative Nurse would give one (1) nurse each shift the posttest for how to care for a resident with Diabetes Mellitus. A score of 100% would be required, if less than 100%, employee would be re-educated and then given the posttest again until 100% compliance was obtained by the Admin/ DON or Restorative Nurse. Beginning 09/22/2020, these audits would be completed three times a week through 10/19/2020. Results of the audits and posttest would be reported to the QA committee (to include but not limited to the Medical Director/ Admin, DON, Restorative Nurse, Dietary Manager, Plant Ops Director, Activities Director, and Medical Records) weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee would determine at what frequency, the audits and administration of the posttest need to continue. The DON would report findings of the audits in QA and any concerns identified would be corrected immediately and reported to Administrator to ensure appropriate follow up is completed. 15. Beginning 09/19/2020 and going through abatement, daily 5 residents with a BIMS of 8 and above would be asked the following questions by the Admin, DON, SSD and/or the MDS Coordinator- 1) Do the staff address your needs?, 2.) If you have a concern or a medical problem, for example a low blood sugar, do the staff respond, notify your doctor and provide treatment if needed? 3.) Do you have any concerns related to your care at this time? Any concerns will be reported to the Administrator or DON immediately and follow up will be completed. Results of the resident interviews, audits and licensed nurse test will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee would determine at what frequency the resident interviews, audits and Licensed Nurse test would need to continue. Concerns identified would be corrected immediately and reported to Administrator to ensure appropriate follow up was completed. 16. Beginning 09/19/2020 and going through abatement, daily 5 residents with BIMS of less than 8 would have an assessment for any signs or symptoms of a change in condition that had not been addressed in the 24 hour lookback period by the Administrator, DON, MDS Coordinator and Restorative Nurse. No new concern were noted. 17. Daily starting 09/19/2020, the Administrator or DON would review the Post Tests given for any noted concerns. Any concerns would be addressed immediately. 18. SCC or other member of the Regional Team, would provide oversight to the audits, three times a week, beginning 09/17/2020 and continuing through abatement. 19. Education on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, an accucheck competency to include training on how to perform a glucose check-disinfection process for glucometer, interpretation of glucose results, documentation of glucose results, process for refusal of glucose by resident to include MD notification, and to promptly report abnormal results to the MD and promptly act on any new orders given by physician, also physician and family notification, completing and SBAR. Abuse/Neglect and Resident Rights would be included in orientation prior to providing resident care. This education would be provided by provided by the DON/ Admin and or designee. The posttest would be given by the Admin/ [NAME] or designee for all new-hire licensed nurses in which a pre-posttest would be given and a score of 100% must be obtained on the post test. 20. Education would be provided by the Administrator/ DON and or designee on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus and licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect would be included in orientation for all new hire [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to implement the care plan for six (6) of eighteen sampled residents (Resident #7, #12, #19, #42, #29 and #250) and failed to develop a person-centered care plan for one (1) residents (Resident #31) out of eighteen (18) sampled residents related to activity preferences. Resident #7, #12, #19, #42, and #250 had care plans related to their diagnosis of Diabetes Mellitus with interventions to complete blood glucose monitoring and/or to monitor for signs/symptoms of Hypoglycemia. However, the facility failed to implement the care plans for these residents related to obtaining blood glucose monitoring and monitoring/notifying the physician of low blood glucose levels. On 08/06/2020, Resident #250's fingerstick blood glucose level was 66 (ADA recommendation range for someone with diabetes: 80-130 mg/dl) at 5:09 PM and was 59 at 8:15 PM. However, the resident's physician was not notified of the resident's low blood glucose level. On 08/07/2020 at 12:26 PM, the resident's blood glucose level was 56. On 08/07/2020 at 5:09 PM, the resident had a blood glucose level of 46. Again the facility failed to notify Resident #250's physician of the low blood glucose level. Approximately, four (4) hours hours later at 9:19 PM, the resident's blood glucose level was 37. The physician was notified and Glucagel (used to treat low blood glucose levels) was ordered orally. Resident #250 requested to be sent to the hospital on [DATE] at 9:30 PM. The facility rechecked Resident #250's blood glucose level and documented the level as being 85 prior to the resident leaving the facility; however, the time was not documented. Review of the ambulance documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level as being 34. The resident was transported to the acute care hospital where he/she required intravenous fluids and medication to maintain his/her blood sugar. Resident #250 was diagnosed with Type 2 Diabetes Mellitus with Hypoglycemia. In addition, review of the record for Resident #29 revealed the facility assessed Resident #29 to be at risk for dehydration and developed care plan interventions that included monitoring fluid intake for the resident. However, the facility failed to document and/or monitor the resident's intake on 09/25/2020, 09/26/2020, and 09/27/2020. The facility failed to develop person-centered care plan interventions related to Resident #31's activity preference of spending time outdoors. The facility's failure to implement the resident's plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/17/2020 and determined to exist on 08/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726). The facility was notified of the Immediate Jeopardy on 09/17/2020. An acceptable Allegation of Compliance was received on 09/23/2020, which alleged removal of Immediate Jeopardy on 09/22/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 09/22/2020 as alleged, prior to exit on 10/01/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Comprehensive Care Plans, last reviewed and revised on 07/19/2018 revealed it is the goal of the facility to develop a person-centered comprehensive care plan that includes measurable objective, and timetables to meet the resident's medical, nursing, mental and psychological needs for each resident. The policy further stated that care plan interventions would be implemented after consideration of the resident's problem areas and their causes. A review of a protocol titled, Hypoglycemia Management Algorithm, with a revision date of 09/01/15, utilized by the facility and developed by the American Diabetes Association, revealed staff were required to notify a resident's physician for blood glucose levels (blood sugar) less than seventy (70). The protocol also revealed if the resident was awake and able to swallow a simple carbohydrate such as juice, regular soda, milk, hard piece of candy, glucose gel, or glucose tablets would be administered. Per the protocol, the blood glucose level would be rechecked after fifteen (15) minutes. The protocol revealed if the blood glucose level was not greater than or equal to seventy (70) the physician would be notified again for further direction. The protocol stated if the blood glucose level was greater than or equal to seventy (70) then a protein or nutrious snack such as yogurt would be administered. 1. A review of Resident #250's closed medical record revealed the facility admitted the resident on 08/05/2020, with diagnoses of Type II Diabetes Mellitus, Hypertension, Malignant Neoplasm of Breast, and Mastectomy with Breast Reconstruction. A review of the Baseline admission Care Plan for Resident #250, undated, revealed the facility identified the resident had a diagnosis of diabetes. The facility developed a goal for the resident not to develop complications. The interventions included to continue medications and blood sugars as ordered. A review of the physician's orders for Resident #250, dated 08/05/2020, revealed the resident had an order for staff to obtain the resident's blood sugar before meals and at bedtime. The resident had physician orders to receive Amaryl four (4) milligrams (mg) daily orally (to lower blood glucose level), Metformin one thousand (1000) mg twice daily orally (to lower blood glucose level), and Januvia one hundred (100) mg daily orally (to lower blood glucose level). A review of Resident #250's Medication Administration Records (MARS), revealed documentation of blood glucose monitoring for Resident #250. On 08/06/2020 at 5:09 PM, the resident had a blood glucose level of 66. On 08/06/2020 at 8:15 PM, the resident had a documented blood glucose level of 59. On 08/07/2020 at 6:00 AM, there was no evidence blood glucose monitoring was completed. Further review revealed on 08/07/2020 at 5:09 PM, the resident's blood glucose level was 46, and on 08/07/2020 at 9:19 PM, the resident had a thirty seven (37) documented blood glucose level. A review of Resident #250's Nurses Notes, revealed no documentation of the resident's physician being notified of low blood glucose levels for the resident, until 08/07/2020 at 2:27 PM, when the resident's physician visited the resident and wrote a physician's order to discontinue administration of Amaryl four (4) mg daily orally (to lower blood glucose level). The next mention of physician notification related to the resident's blood glucose levels was on 08/07/2020 at 9:30 PM. The nurses notes further revealed on 08/07/2020 at 9:30 PM, Resident #1's physician was notified due to the resident having a blood glucose level of thirty seven (37), and a new order was received to administer Glucose Gel (to raise blood glucose level) orally now and to discontinue both Metformin one thousand (1000) mg twice daily orally (to lower blood glucose level) and Januvia one hundred (100) mg daily orally (to lower blood glucose level). The nurse documented when she entered the resident's room to administer the Glucose Gel (to raise blood glucose level), the resident stated he/she wanted to be transferred to the hospital. The nurse documented she had notified the resident's physician and arrangements were made to transfer the resident to the hospital. The nurses's notes revealed the resident's blood glucose level was rechecked after he/she was administered Glucose Gel (to raise blood glucose level). However no time was documented when the blood glucose level was obtained. The results were documented as being 85 and the resident was documented as being lethargic and very difficult to arouse. The nurses notes revealed the ambulance service arrived at the facility on 08/07/2020 at 10:27 PM, and departed from the facility to the hospital on [DATE] at 10:34 PM. A review of the ambulance service documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level as being 34. The ambulance record revealed an intravenous line was obtained and 50% Dextrose 25 mg intravenously (used to increase blood glucose level) was administered. The ambulance record revealed the resident opened his/her eyes and was able to nod answers to questions. The ambulance record revealed a second 50% Dextrose 25 mg intravenously was administered and then the resident was able to speak in sentences and move his/her extremities independently. The ambulance documentation revealed the resident was then transferred to the acute care hospital. A review of the acute care hospital record for Resident #250, revealed the resident arrived at the hospital on [DATE] at 11:35 PM. The hospital medical record revealed the resident received a D5W intravenous drip. On 08/07/2020 at 11:45 PM, a blood glucose level of sixty nine (69) was documented and 50% Dextrose 25 mg was administered intravenously. The acute care hospital record further revealed on 08/08/2020 at 1:45 AM, the resident's blood glucose level was documented as being less than 60 and an additional 50% Dextrose 25 mg was administered. The acute care hospital record revealed the resident was admitted by the acute care hospital on [DATE] at 4:19 AM with a diagnoses of Type 2 Diabetes Mellitus with Hypoglycemia. An interview with Licensed Practical Nurse (LPN) #2, on 09/14/2020 at 6:51 PM, revealed she had helped LPN #3 on 08/07/2020 at 9:19 PM when Resident #250's blood glucose level was 37. The LPN stated she had told LPN #3 to notify Resident #250's physician. LPN #2 stated LPN #3 had administered Glucagel (to raise blood glucose level) and had rechecked the blood glucose level and it was 85. The LPN stated she had assisted LPN #3 with the resident until the resident was sent out of the facility to the acute care hospital. The LPN stated the resident was lethargic. The LPN stated she had not been aware of the Hypoglycemia Management Algorithm. The LPN stated she had only worked at the facility approximately three (3) weeks when the incident occurred. An interview conducted with LPN #3, on 09/15/2020 at 5:45 PM, revealed she was responsible for conducting the blood glucose monitoring, on 08/06/2020 at 8:15 PM, for Resident #250. The LPN stated she was not aware of the Hypoglycemia Management Algorithm on 08/06/2020 and 08/07/2020, when she was responsible for obtaining Resident #250's blood glucose levels. The LPN stated she was unsure why there was no documented evidence the resident's blood sugar was obtained, on 08/07/2020 at 6:00 AM. She stated she probably obtained the resident's blood sugar, but was unable to recall the result. The LPN stated she guessed she should have notified the physician, on 08/06/2020 at 8:15 PM, when Resident #1's blood glucose level was 59. An interview conducted with LPN #7, on 09/16/2020 at 8:46 AM, revealed she had completed the blood glucose monitoring for Resident #250, on the 7:00 AM to 7:00 PM shift on 08/06/2020. The LPN stated on 08/06/2020 at 5:00 PM, the resident's blood glucose level was 66. The LPN stated she had done nothing because she knew resident would be receiving a supper meal tray and the resident had ate well. LPN #7 stated she did not repeat the blood glucose monitoring nor did she notify the physician but should have. The LPN stated she had not been aware of the Hypoglycemia Management Algorithm until after the inservice on 08/11/2020. An interview conducted with Resident #250's Physician, on 09/16/2020 at 10:00 AM, revealed he had been notified and had been aware of Resident #1's blood glucose level on 08/07/2020 at 12:26 PM and on 08/07/2020 at 9:19 PM. The physician stated the facility did not notify him of the resident's blood glucose levels on 08/06/2020 at 5:00 PM of sixty six (66); or the level on 08/06/2020 at 8:15 PM of fifty nine (59); nor of the 08/07/2020 at 5:09 PM, level of forty six (46). The physician stated he should have been notified and would probably have changed the resident's orders. 2. Review of Resident #7's medical record revealed the facility admitted the resident on 04/10/2019, with diagnoses including Diabetes Mellitus and Stage IV Kidney Disease. Review of Physician Orders for Resident #7, dated 05/30/2020, revealed staff were to obtain the resident's blood glucose level before meals and at bedtime. In addition, physician orders dated 07/08/2020, revealed staff were to administer Resident #7, six (6) units of Lantus insulin subcutaneously every morning, and five (5) units of Novolin R insulin before meals. Review of Resident #7's Minimum Data Set (MDS) assessment, dated 07/08/2020, revealed the resident had a BIMS score of four (4) which revealed the facility assessed the resident to be severely impaired cognition. Review of Resident #7's Comprehensive Care Plan, reviewed on 07/14/2020, revealed interventions directed staff to manage the resident's Diabetes Mellitus by performing blood glucose monitoring as ordered, observe the resident for signs/symptoms of hypoglycemia and report any concerns to the physician. Review of Resident #7's Medication Administration Record (MAR), revealed the resident's blood glucose levels, on 08/31/2020 at 4:40 PM, was 64 mg/dl, on 09/03/2020 at 5:08 PM, the resident's blood glucose level was 63 mg/dl, and on 09/08/2020 at 8:08 PM, the resident's glucose level was 65 mg/dl. However, there was no evidence found to indicate the staff notified the resident's physician or the resident's blood glucose levels were monitored or rechecked by staff. Resident # 7 was observed, on 09/29/20 at 9:21 AM, to be resting with his/her eyes closed. No signs or symptoms of hypoglycemia was observed. Interview with LPN #6, on 09/17/2020 at 1:30 PM, revealed she obtained Resident #7's blood glucose level on 08/31/2020 at 4:40 PM, however, she had not rechecked the resident's blood glucose level after obtaining a reading of below 70 mg/dl, or notified the resident's physician of the resident's low glucose level. LPN #6 stated she was unaware of the facility's Hypoglycemia Management Algorithm policy that staff was to utilize when a resident experienced a hypoglycemic episode. Although the LPN stated she had attended the facility's annual in-service on how to perform blood glucose monitoring, the in-service did not address what action to take if a resident's blood glucose level was low. LPN #6 stated she took no further action related to Resident #6's blood glucose level on 08/31/2020, because the resident's blood glucose level was not below 60 mg/dl. Interview with LPN #7, on 09/17/2020 at 10:50 AM, revealed she obtained Resident #7's blood glucose level on 09/03/2020 at 5:08 PM, when the resident's glucose level was 63 mg/dl. The LPN stated she did not notified the resident's physician or recheck the resident's glucose level in fifteen (15) minutes as required by the facility's policy. LPN #7 stated she had not been aware of the facility's Hypoglycemia Management Algorithm protocol. Further interview with LPN #7, revealed she attended the facility's in-service on performing blood glucose, however, the in-service did not address what to do if a resident experienced hypoglycemia. Interview with Registered Nurse (RN) #2, on 09/16/2020 at 8:20 AM, revealed she obtained Resident #7's blood glucose level, on 09/08/2020 at 8:08 PM, when the resident's blood glucose level was 65 mg/dl. However, RN #2 stated she had not notified the resident's physician of the low blood glucose level or rechecked the resident's blood glucose level in fifteen (15) minutes as required. Continued interview with the RN revealed she had been aware of the facility's Hypoglycemia Management Algorithm, but felt she could manage the resident's hypoglycemia on her own, and did not need to notify the physician. RN #2 stated she had given the resident a peanut butter sandwich and a cup of orange juice, which the resident had eaten, and therefore she did not feel like she needed to recheck the resident's blood glucose level. RN #2 stated she attended the facility's in-services on how to perform blood glucose monitoring, but could not recall if managing a resident who was hypoglycemic was discussed. 3. Review of Resident #19's medical record revealed the facility admitted the resident on 12/17/2019, with diagnoses including Diabetes Mellitus, Atrial Fibrillation, and Anxiety. Review of Resident #19's MDS assessment dated [DATE], revealed the resident had a BIMS score of nine (9) which indicated the resident had been assessed to have moderately impaired cognition. Review of Resident #19's Comprehensive Care Plan, revised on 09/02/2020, revealed interventions to manage the resident's Diabetes Mellitus included observing the resident's for signs and symptoms of hypoglycemia, administering the resident a Glucagon injection if the resident's blood glucose level was less than 60 mg/dl and the resident had difficulty responding, providing blood glucose monitoring as ordered, and notifying the resident's physician with significant changes. Review of Physician Orders for Resident #19, dated 08/24/2020, revealed staff were to obtain the resident's blood glucose levels before meals. Further review of the orders revealed an order, dated 09/02/2020, for the resident to receive Novolin R insulin 12 units subcutaneously after breakfast and lunch, and 8 units after the evening meal, unless the resident does not eat a lot only administer one half the dose. Review of Resident #19's MARS for September 2020, revealed on 09/06/2020 at 5:03 PM, staff documented the resident's blood glucose level was 64 and no insulin was administered. However, there was no evidence the staff notified the resident's physician or that the resident's blood glucose level was rechecked or monitored per the facility protocol and care plan. Resident #19 was observed on 09/30/2020 9:31 AM, ambulating in hall. No signs of hypoglycemia were observed. Interview conducted with Resident #19, on 09/30/2020 at 9:15 AM, revealed the resident had no concerns with blood glucose monitoring done by the facility. Interview on 09/17/2020 with LPN #9 at 10:40 AM, revealed the LPN was aware of the facility's Hypoglycemia Management Algorithm, and nursing was to notify the physician and recheck Resident #19's glucose level, on 09/06/2020 at 5:03 PM, and stated she did not know why she had not done it as required. 4. Review of Resident #12's medical record revealed the facility admitted the resident on 05/13/2020, with diagnoses including Diabetes Mellitus and Chronic Kidney Disease. Review of Resident #12's MDS assessment, dated 08/12/2020, revealed the resident had a BIMS score of fifteen (15) which indicated the resident had been assessed to have no concerns with cognition. Review of Resident #12's Comprehensive Care Plan revised on 08/14/2020, revealed interventions implemented to address the resident's Diabetes Mellitus included providing blood glucose monitoring as ordered, notifying the physician with significant changes, and observing for signs and symptoms of hypoglycemia. Review of the Physician's Orders for Resident #12, dated 05/25/2020, revealed an order for staff to obtain the resident's blood glucose level before meals. In addition, the facility received an order on 06/5/2020, for the resident to receive Novolog insulin 8 units subcutaneously before meals. Review of Resident #12's MARS for September 2020, revealed on 09/03/2020 at 5:13 AM, the resident's blood glucose level was 61 mg/dl, and on 09/09/2020 at 5:22 AM, the resident's blood glucose level was 64 mg/dl. However, there was no evidence the staff notified the physician of the resident's low blood glucose levels or that the glucose level was rechecked or monitored as required. Observation of Resident #12 on 09/29/2020 at 11:30 AM, revealed the resident was observed to be sitting in his/her wheelchair in the resident's room. No signs or symptoms of hypoglycemia were observed. Interview conducted with Resident #12, on 09/29/2020 at 11:35 AM, revealed the resident stated he/she had no concerns with the blood glucose monitoring provided to him/her by the facility. Interview with LPN #2, on 09/17/2020 at 10:00 AM, revealed she was not aware of the facility's Hypoglycemia Management Algorithm protocol. The LPN stated she should have rechecked and monitored the resident's blood glucose level and provided the resident a snack. 5. Review of Resident #42's medical record revealed the facility admitted the resident on 09/25/2019, with diagnoses including Diabetes Mellitus and Chronic Kidney Disease. Review of Resident #42's MDS assessment, dated 09/08/2020, revealed the facility assessed the resident to have a BIMS score of fifteen (15), which indicated the resident had been assessed to have no concerns with cognition. Review of Resident #42's Comprehensive Care Plan, revised on 09/11/2020, revealed interventions implemented to manage the resident's Diabetes Mellitus included monitoring the resident's glucose levels, notifying the resident's physician of any significant changes in signs and symptoms, and observing for signs and symptoms of hypoglycemia. Review of Physician Orders for Resident #42, revealed an order dated 11/04/2019, for staff to obtain the resident's blood glucose level before meals and at bedtime, and an order dated 04/24/2020, for the resident to receive Tresiba insulin subcutaneously every morning. Review of Resident #42's MARS for September 2020, revealed on 08/20/2020 at 4:40 PM, revealed the resident's blood glucose level was 64 mg/dl, 08/22/2020 at 4:44 PM, the resident's blood glucose level was 64 mg/dl, and on 09/03/2020 at 11:54 AM, the resident's blood glucose level was 57 mg/dl. However, there was no evidence the physician was notified or the resident's blood glucose level was rechecked or monitored as required. Observation of Resident #42 on 09/30/2020 at 10:45 AM, revealed the resident was observed to be up in a wheelchair in his/her room. No signs or symptoms hypoglycemia observed. Interview with Resident #42, on 09/30/2020 at 10:50 AM, revealed the resident stated he/she had no concerns regarding the care he/she received by the facility. Interview with LPN #9, on 09/17/2020 at 10:40 AM, revealed the LPN was aware of the facility's Hypoglycemia Management Algorithm and was aware that any time a resident was hypoglycemic she was required to notify the physician and recheck the blood glucose level. However, LPN #9 stated she failed to follow the facility's policy hypoglycemic management for Resident #42, on 08/20/2020 at 4:40 PM, 08/22/2020 at 4:44 PM, and on 09/03/2020 at 11:54 AM, when the resident was hypoglycemic. The LPN stated she should have rechecked the blood glucose level after providing the resident a snack and notified the resident's physician. A post-survey interview with the Director of Nursing (DON) on 10/14/2020 at 8:14 AM, revealed she made rounds daily and attended the Interdisciplinary Team Meeting (IDT) daily Monday through Friday. The resident's care plans were reviewed every morning in the IDT meeting to make sure things were in place for all residents. The DON stated the facility also reviewed all new physician's orders to ensure they have been added to the care plan if needed. She stated Resident #250, Resident #7, Resident #12, Resident #19, and Resident #42's physicians should have been notified when their blood glucose levels dropped to seventy (70) or below. A post-survey interview, on 10/14/2020 at 8:20 AM, with the MDS Coordinator, revealed she was responsible for developing the comprehensive care plans for all residents. The MDS Coordinator stated the admitting nurse was responsible for completing the interim (baseline) care plan, which was then reviewed in the daily IDT meeting Monday through Friday. The MDS Coordinator stated the care plans were reviewed and any needed changes would be made to the care plans. The MDS Coordinator further stated all new physician orders were reviewed daily and to ensure they had been added to the care plan if needed. The MDS Coordinator stated Resident #250, Resident #7, Resident #12, Resident #19, and Resident #42's physician should have been notified when their blood glucose levels dropped to seventy (70) or below. The MDS Coordinator stated she utilized a care plan template for diabetics, and all diabetics had interventions to monitor for hypoglycemia or hyperglycemia, and to notify the physician for any signs or symptoms of hypoglycemia or hyperglycemia. A post-survey interview on 10/14/2020 at 8:30 AM with the Administrator revealed the baseline care plan was completed by the admitting nurse when a resident was admitted . The Administrator stated the care plan would then be reviewed in the IDT meeting every morning Monday through Friday to ensure everything was in place for the resident. The Administrator stated Resident #250, Resident #7, Resident #12, Resident #19, and Resident #42's physician should have been notified when their blood glucose levels dropped to seventy (70) or below per each resident's care plan. 6. Review of the record for Resident #29 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Diabetes, Hypertension, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/05/2020, revealed the facility assessed the resident's mental status with a Brief Interview for Mental Status (BIMS) and the resident scored a four (4) indicating severe cognitive impairment. The assessment further noted the resident was able to make himself/herself understood and the resident was totally dependent upon one (1) staff person for eating and drinking. Review of the comprehensive care plan revealed the problem of Nutritional Status with a problem start date of 08/08/2019. The care plan stated that the resident was at nutritional and hydration risk and interventions included Monitor intake of food and liquids. Further review of the record for Resident #29 revealed, on 09/25/2020 and 09/26/2020, there was no fluid intake documented for the resident and only 480 ml was documented as intake for 09/27/2020. Observation of Resident #29 on 09/29/2020 at 3:18 PM revealed the resident was awake and alert and had a pitcher of ice water available at the bedside. Observation on 09/30/2020 at 10:50 AM revealed the resident was in the room in bed and asked for a drink of water. The resident had water at the bedside on the bedside table that appeared to be within the resident's reach, but the resident stated I can't get it. A staff member passed by the room, entered the room and assisted the resident to drink water from the water pitcher/container at the bedside. Interview with Certified Nursing Assistant (CNA) #7 on 10/01/2020 at 10:06 AM revealed that they are required to document fluid intake on residents. CNA #7 stated that Resident #29 asks for a drink often and he/she is given drinks of water several times throughout the day. CNA #7 stated that sometimes the intake may not be documented because staff just forget to document it. Interview on 10/01/2020 at 10:11 AM with Licensed Practical Nurse (LPN) #10 revealed that the nurses monitor each resident's hydration status daily. LPN #10 stated that the fluid intake is documented in the computer and the Director of Nursing (DON) monitors the intakes to ensure that residents are meeting their needs. Interview with the DON and the Facility Administrator on 10/01/2020 at 1:37 PM revealed that the Dietary Manager reviews the residents fluid needs daily and if there are concerns with a resident not meeting their recommended fluid needs, the Dietary Manager brings the concern to the morning clinical meeting for discussion with the Interdisciplinary team (IDT). The Administrator stated that the Dietary Manager is currently on sick leave and the Dietitian has been reviewing the intakes while the Dietary Manager was off and the Dietitian had not reported any concerns with fluid intake or gaps in the documentation for any residents. 7. Review of Resident #31's Clinical Record revealed the facility admitted the resident on 12/04/2019 with diagnosis of Charcot's joint right knee, Type 1 Diabetes Mellitus with Ketoacidosis without Coma, Rheumatoid Arthritis, Methicillin Resistant Staphylococcus Aureus infection, and Urinary Tract Infection. Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of fourteen (14) out of fifteen (15), which indicates the resident is cognitively intact. Review of Resident #31's admission MDS dated [DATE] revealed it was very important to the resident to go outside for fresh air when the weather was nice. Review of the most recent quarterly MDS completed on 09/03/2020 revealed resident #31 was assessed to be independent with transfers, and be independent with locomotion on and off the unit. Review of Resident #31 Comprehensive Care Plan for the category of Activities dated 04/24/2020 revealed that the resident enjoyed going outside when the weather was good. The Care Plan had no interventions that addressed how to ensure the resident participates in the activity of going outside. Interview with Resident #31, on 09/29/2020 09:46 AM, revealed that he/she was never allowed to go outside. The resident stated he/she was not allowed to go outside unless he/she was going to a doctor's appointment. The resident stated she enjoyed being outside when the weather was nice. Observation on 09/29/2020 at 9:46 AM, 09/30/2020 at 10:24 AM, and 10/01/2020 at 1:19 PM, revealed Resident #31 was in his/her room, despite the sunny, mild weather. Interview with Licensed Practical Nurse (LPN #10), on 10/01/2020 9:39 AM, revealed she thought Resident #31 could go to the courtyard if he/she wanted to. She further stated that any staff could take the resident outside when asked. Interview with Activities Director, on 10/01/2020 at 10:24 AM, revealed that residents were permitted to go outside; however, it had been a while since Resident #31 had asked to go outside. The Activity Director further stated that she gauges allowing residents to go outside on the amount of staff that was available to watch them. Interview with the MDS Coordinator, on 10/01/2020 at 2:26 PM, revealed the activities department develops the care plan for activities. MDS Coordinator further indicated that care plans are reviewed during clinical morning meetings to ensure accuracy. Interview with Activity Director, on 10/01/2020 at 2:26 PM, revealed she developed the care plan for activities for residents of the facility. She further stated care plans were reviewed by the interdisciplinary team during the quarterly care plan meetings, and the Activity Director stated she was unaware the care plan did not include resident specific interventions related to Resident #31 preference to go outside. The facility alleged the following was implemented to remove Immediate Jeopardy on 09/22/2020: 1. Education related to documentation of blood glucose checks, physician notification, and documentation of physician notification related to change in resident's condition was initiated on 08/11/2020, and completed on 08/14/2020 for all licensed nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received care and treatment in accordance with accepted standards of practice to treat and prevent adverse events related to hypoglycemia (low blood sugar) for five (5) of eighteen (18) sampled residents (Resident #250, Resident #7, Resident #19, Resident #12, and Resident #42). Review of the facility's Hypoglycemia Management Algorithm, developed by the American Diabetes Association, revealed if a resident's blood sugar was less than or equal to 70 milligrams per deciliter (mg/dl), staff were required to notify the resident's physician, recheck the resident's blood sugar in 15 minutes, then take other necessary actions based on the resident's blood sugar result. (Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than normal and needs immediate treatment). However, on [DATE] at 5:00 PM and 8:15 PM, Resident #1's blood sugar was less than 70 mg/dl (66 and 59) and there was no evidence the Hypoglycemia Algorithm was initiated; subsequently, there was no evidence the facility assessed the resident, nor reassessed the resident's blood sugar. In addition, staff continued to administer medication to lower the resident's blood sugar. On [DATE], the facility failed to check the resident's blood sugar as ordered by the resident's physician at 6:00 AM. Record review revealed staff administered three (3) oral medications to lower the resident's blood sugar without knowledge of the resident's blood sugar level. At 12:26 PM, on [DATE], the resident's blood sugar was 56 mg/dl. Staff notified the resident's physician, but failed to implement the hypoglycemia protocol and reassess the resident per the algorithm. At 5:09 PM on [DATE], the resident's blood sugar had dropped to 46 mg/dl. Again, staff failed to implement the Hypoglycemia Algorithm and took no action to address the resident's low blood sugar. In addition, staff documented that medication was administered to lower the resident's blood sugar, despite the low blood sugar level. By 9:19 PM, on [DATE], the resident's blood sugar was 37 mg/dl. The facility notified the resident's physician, administered glucose gel (increases blood sugar), and the resident's blood sugar increased to 85 mg/dl, at which time the resident requested to be transferred to the hospital. However, by 10:21 PM on [DATE], staff documented the resident was lethargic and difficult to arouse (signs that hypoglycemia had worsened) and there was no evidence staff took any action to assess/treat the resident. When Emergency Medical Services (EMS) arrived, the resident's blood sugar was 33 mg/dl and the resident was unresponsive (late signs of hypoglycemia). The resident was transferred and admitted to an acute care hospital where he/she required intravenous therapy (IV) to treat his/her low blood sugar. In addition, review of the medical records for Resident #7, Resident #19, Resident #12, and Resident #42, revealed when the residents had blood glucose levels less than 70 mg/dl, there was no evidence the facility implemented the Hypoglycemia Management Algorithm; subsequently, there was no evidence the physicians were notified, nor was repeat blood glucose monitoring completed. The facility's failure to ensure residents received appropriate care and treatment in accordance with accepted standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled,Blood Glucose Monitoring, reviewed [DATE], revealed upon a diagnosis of hypoglycemia, the critically low glucose level was required to be treated per facility policy for treatment of hypoglycemia. Review of a facility protocol titled, Hypoglycemia Management Algorithm, revised [DATE], developed by the American Diabetes Association, revealed staff were required to notify a resident's physician for blood glucose levels (blood sugar) less than 70 mg/dl. The protocol also revealed if the resident was awake and able to swallow a simple carbohydrate such as juice, regular soda, milk, hard piece of candy, glucose gel, or glucose tablets would be provided. According to the protocol, the facility was required to recheck the resident's blood glucose level after 15 minutes. The protocol stated if the blood glucose level was greater than or equal to 70, a protein or nutritious snack such as yogurt should be provided and the family member and physician would be notified. However, if the blood glucose level was still not greater than or equal to 70, the physician should be notified for further direction. Interview conducted with the Director of Nursing (DON) on [DATE] at 2:30 PM, revealed the facility did not have a policy regarding nursing assessment and utilized the facility's Change of Condition policy related to resident assessment. Review of the facility's policy titled, Change of Condition, with a revision date of [DATE], revealed the facility would evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner, to relay evaluation information to the physician and to document actions. 1. Review of Resident #250's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses of Type II Diabetes Mellitus, Hypertension, Malignant Neoplasm of Breast, Mastectomy with Breast Reconstruction. Review of Resident #250's Baseline admission Care Plan, undated, revealed the facility identified the resident had a diagnosis of diabetes. The facility developed a goal for the resident not to develop complications from diabetes, and developed interventions to administer medications and to obtain blood sugars as ordered. Review of Resident #250's Physician Orders, dated [DATE], revealed the resident had an order for staff to obtain the resident's blood sugar before meals and at bedtime. The physicians orders also revealed the resident had orders to receive Amaryl four (4) milligrams (mg) daily orally (to lower blood glucose level), Metformin 1000 mg twice daily orally (to lower blood glucose level), and Januvia 100 mg daily orally (to lower blood glucose level). Review of Resident #250's Medication Administration Record (MAR), revealed the facility was required to obtain the resident's blood sugar at 6:00 AM, 11:15 AM, 5:00 PM, and 9:00 PM, daily. Continued review revealed on [DATE], the day after admission to the facility, at 5:09 PM, the resident's blood sugar level was 66 mg/dl. There was no evidence the facility assessed the resident's condition to relay findings to the physician as required by the facility's change in condition protocol or implemented the hypoglycemia management algorithm that required staff to take action and re-evaluate the resident in 15 minutes. Interview conducted with Licensed Practical Nurse (LPN) #7, on [DATE] at 8:46 AM, revealed she obtained Resident #250's blood sugar, on [DATE] at 5:09 PM. The LPN stated she took no action because the resident had not eaten the evening meal and believed meal intake would increase the resident's blood sugar. The LPN stated she did not reassess Resident #250's blood sugar as required by the hypoglycemia algorithm because, at the time, she was not aware that the protocol existed. Further review of Resident #250's MAR revealed approximately three (3) hours later, on [DATE] at 8:15 PM, the resident's blood sugar was 59. Again, there was no evidence the facility assessed the resident, nor implemented the hypoglycemia algorithm to address the resident's low blood sugar. In addition, according to the resident's MAR, staff administered Metformin to the resident, on [DATE] between 4:00 PM and 11:00 PM (exact time not documented), with no evidence the resident's blood sugar was monitored any further, until [DATE] at 12:26 PM, when the resident's blood sugar was 56. Even though there was no documented evidence staff obtained Resident #250's blood sugar, on [DATE] at 6:00 AM, as ordered by the resident's physician, staff documented that medications were administered to lower the resident's blood sugar. According to Resident #250's MAR, the resident received Metformin on [DATE] between at 6:00 AM and 11:00 AM (exact time not documented), and Amaryl and Januvia, on [DATE] between 7:15 AM and 11:00 AM (exact time not documented). Interview conducted with LPN #3, on [DATE] at 5:45 PM, revealed she was responsible for Resident #250's care on 08/06-07/2020, during the night shift (7:00 PM-7:00 AM). LPN #3 stated she obtained the resident's blood sugar, on [DATE] at 8:15 PM, but did not implement the hypoglycemia algorithm or reassess the resident, because she was not aware of the protocol. According to LPN #3, she was unsure why there was no documented evidence that the resident's blood sugar was obtained, on [DATE] at 6:00 AM. She stated she probably obtained the resident's blood sugar, but was unable to recall the result. Review of the Nurses Notes for Resident #250, revealed on [DATE] at 2:27 PM, the resident's physician visited the resident as a result of the low blood sugar at 12:26 PM, and wrote a physician's order to discontinue Amaryl. However, the resident had already received the medication that day. In addition, staff documented that Metformin medication was administered to the resident on [DATE] between 4:00 PM and 11:00 PM (exact time not documented). Continued review of Resident #250's MAR, revealed on [DATE] at 5:09 PM, the resident's blood sugar continued to decrease at 46 mg/dl. However, there was no evidence the hypoglycemia protocol was implemented, nor was there documentation that the resident was assessed/reassessed to determine whether further action was needed. Interview conducted with LPN #1, on [DATE] at 6:25 PM, revealed on [DATE] at 12:26 PM, she notified the resident's physician of the resident's blood sugar result and gave the resident orange juice. The LPN stated the physician was at the facility and saw the resident. The LPN stated she had observed the resident eat his/her lunch meal; however, she did not recheck the resident's blood glucose level and was not aware she should have. Further interview with the LPN revealed when the resident's blood glucose level was 46 mg/dl, on [DATE] at 5:09 PM, she gave the resident a cup of orange juice and asked if he/she would like a peanut butter sandwich. The resident declined the peanut butter sandwich and stated his/her family was bringing a piece of cheesecake. The LPN stated she did not recheck the resident's blood glucose level, nor did she notified the resident's physician. According to the LPN, she was not aware of the facility's Hypoglycemia Management Algorithm. Further review of Resident #250's MAR, revealed no evidence staff checked the resident's blood sugar again until 9:19 PM, on [DATE] when it was 37 mg/dl. Review of Resident #250's Nurses' Notes revealed, on [DATE] at 9:30 PM, Resident #1's physician was notified the resident's blood sugar was 37 mg/dl and a new order was received to administer Glucose Gel (to raise blood glucose level) orally and to discontinue both Metformin and Januvia. However, according to the MAR, the medications had already been administered, on [DATE]. Further review of the nurse's note revealed when the nurse entered the resident's room to administer Glucose Gel, the resident asked to be transferred to the hospital. The nurse documented she had notified the resident's physician and arrangements were made to transfer the resident to the hospital. The nurses's notes revealed the resident's blood glucose level was rechecked after Glucose Gel was administered (time not documented) and was 85 mg/dl. Continued review of Resident #250's nurses notes revealed, on [DATE] at 10:27 PM, staff documented that the resident was lethargic and very difficult to arouse. However, there was no evidence the facility assessed the resident's blood sugar or took any other action to address the resident's condition. Continued interview with LPN #3, on [DATE] at 5:45 PM, revealed she was responsible for Resident #250's care, on [DATE] at 9:19 PM, when the resident's blood sugar was 37 mg/dl. The LPN stated she notified the resident's physician, administered Glucogel, and made arrangements to transfer the resident to the hospital per the resident's request. According to LPN #3 she rechecked the resident's blood sugar after administering Glucogel and it was 85 mg/dl (not sure of the time). The LPN stated she should have reassessed the resident again when he/she was lethargic prior to the EMS arrival at the facility and stated she did not know why a reassessment was not completed. Interview conducted with Resident #250's Physician, on [DATE] at 10:00 AM, revealed staff should have assessed the resident and followed the facility's. Hypoglycemia Management Algorithm. The physician stated Resident #250 could have expired from a low blood glucose level. Review of EMS documentation for Resident #250 revealed, on [DATE] at 10:51 PM, the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level was 34 mg/dl. According to the report, EMS obtained an intravenous (IV) line and administered 50% Dextrose intravenously (used to rapidly increase blood sugar levels). After the Dextrose, the resident was able to open his/her eyes and was able to nod answers to questions. The EMS report revealed a second 50% Dextrose dose was administered and the resident was able to speak in sentences and move his/her extremities independently. Interview conducted with Advanced Emergency Medical Technician (EMT), on [DATE] at 9:50 AM, confirmed Resident #250 was unresponsive when she arrived at the facility to transport the resident to the acute care hospital. The EMT stated when she and her partner transported the resident into the ambulance, the resident's blood sugar was 34 mg/dl and took two (2) doses of Dextrose for the resident to be able to speak in sentences and move his/her extremities. Review of the Acute Care Hospital record for Resident #250, revealed the resident arrived at the hospital, on [DATE] at 11:35 PM. The resident's blood sugar on arrival was 69 mg/dl at 11:45 PM, and a D5W (dextrose) IV continuous drip was initiated and 50% Dextrose twenty five (25) mg administered intravenously. Resident #250 was admitted to the acute care hospital with a diagnoses of Type 2 Diabetes Mellitus with Hypoglycemia. Resident #250 was discharged from the facility on [DATE]. Attempted to interview the resident via phone, on [DATE] at 11:15 AM, [DATE] at 4:30 PM , [DATE] at 12:15 PM and [DATE] at 10:30 AM were unsuccessful. Interview conducted with the Director of Nursing (DON), on [DATE] at 2:30 PM, and with the Administrator, on [DATE] at 3:00 PM, revealed nurses were required to implement the Hypoglycemia Management Algorithm anytime a resident had a blood glucose level of 70 or lower. The DON stated she was not aware the algorithm was not being implemented until after the incidents with Resident #250. 2. Review of Resident #7's medical record revealed the facility admitted the resident on [DATE], with diagnoses including Diabetes Mellitus and Stage IV Kidney Disease. Review of Physician Orders for Resident #7, dated [DATE], revealed staff were to obtain the resident's blood glucose level before meals and at bedtime. In addition, physician orders dated [DATE], revealed staff were to administer Resident #7, six (6) units of Lantus insulin subcutaneously every morning, and five (5) units of Novolin R insulin before meals. Review of Resident #7's Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a BIMS score of four (4) which revealed the facility assessed the resident to be severely impaired cognition. Review of Resident #7's Comprehensive Care Plan, reviewed on [DATE], revealed interventions directed staff to manage the resident's Diabetes Mellitus by performing blood glucose monitoring as ordered, observe the resident for signs/symptoms of hypoglycemia and report any concerns to the physician. Review of Resident #7's Medication Administration Record (MAR), revealed the resident's blood glucose levels on [DATE] at 4:40 PM was 64 mg/dl, on [DATE] at 5:08 PM the resident's blood glucose level was 63 mg/dl and on [DATE] at 8:08 PM the resident's glucose level was 65 mg/dl. However, there was no evidence found to indicate that the staff notified the resident's physician or the resident's blood glucose levels were monitored or rechecked by staff. Resident # 7 was observed on [DATE] at 9:21 AM, to be resting with his/her eyes closed. No signs or symptoms of hypoglycemia was observed. Interview with LPN #6 on [DATE] at 1:30 PM, revealed she obtained Resident #7's blood glucose level on [DATE] at 4:40 PM, however, she had not recheck the resident's blood glucose level after obtaining a reading of below 70 mg/dl or notified the resident's physician of the resident's low glucose level. LPN #6 stated she was unaware of the facility's Hypoglycemia Management Algorithm policy that staff was to utilize when a resident experienced a hypoglycemic episode. Although the LPN stated she had attended the facility's annual in-service on how to perform blood glucose monitoring, the in-service did not address what action to take if a resident's blood glucose level was low. LPN #6 stated she took no further action related to Resident #6's blood glucose level on [DATE] because the resident's blood glucose level was not below 60 mg/dl. Interview with LPN #7 on [DATE] at 10:50 AM, revealed she obtained Resident #7's blood glucose level on [DATE] at 5:08 PM, when the resident's glucose level was 63 mg/dl. The LPN stated she did not notified the resident's physician or recheck the resident's glucose level in fifteen (15) minutes as required by the facility's policy. LPN #7 stated she had not been aware of the facility's Hypoglycemia Management Algorithm. Further interview with LPN #7 revealed she attended the facility's in-service on performing blood glucose, however, the in-service did not address what to do if a resident experienced hypoglycemia. Interview with Registered Nurse (RN) #2, on [DATE] at 8:20 AM, revealed she obtained Resident #7's blood glucose level, on [DATE] at 8:08 PM, when the resident's blood glucose level was 65 mg/dl. However, RN #2 stated she had not notified the resident's physician of the low blood glucose level or rechecked the resident's blood glucose level in fifteen (15) minutes as required. Continued interview with the RN revealed she had been aware of the facility's Hypoglycemia Management Algorithm, but felt she could manage the resident's hypoglycemia on her own, and did not need to notify the physician. RN #2 stated she had given the resident a peanut butter sandwich and a cup of orange juice, which the resident had eaten, and therefore she did not feel like she needed to recheck the resident's blood glucose level. RN #2 stated she attended the facility's in-services on how to perform blood glucose monitoring, but could not recall if managing a resident who was hypoglycemic was discussed. 3. Review of Resident #19's medical record revealed the facility admitted the resident on [DATE], with diagnoses including Diabetes Mellitus, Atrial Fibrillation, and Anxiety. Review of Resident #19's MDS assessment dated [DATE] revealed the resident had a BIMS score of nine (9) which indicated the resident had been assessed to have moderately impaired cognition. Review of Resident #19's Comprehensive Care Plan, revised on [DATE], revealed interventions to manage the resident's Diabetes Mellitus included observing the resident's for signs and symptoms of hypoglycemia, administering the resident a Glucagon injection if the resident's blood glucose level was less than 60 mg/dl and the resident had difficulty responding, providing blood glucose monitoring as ordered, and notifying the resident's physician with significant changes. Review of Physician Orders for Resident #19, dated [DATE], revealed staff were to obtain the resident's blood glucose levels before meals. Further review of the orders revealed an order, dated [DATE], for the resident to receive Novolin R insulin 12 units subcutaneously after breakfast and lunch, and 8 units after the evening meal, unless the resident does not eat a lot only administer one half the dose. Review of Resident #19's MARS for [DATE], revealed on [DATE] at 5:03 PM, staff documented the resident's blood glucose level was 64 and no insulin was administered. However, there was no evidence the staff notified the resident's physician or that the resident's blood glucose level was rechecked or monitored. Resident #19 was observed on [DATE] 9:31 AM, ambulating in hall. No signs of hypoglycemia were observed. Interview conducted with Resident #19 on [DATE] at 9:15 AM, revealed the resident had no concerns with blood glucose monitoring done by the facility. Interview on [DATE] with LPN #9 at 10:40 AM, revealed the LPN was aware of the facility's Hypoglycemia Management Algorithm, and that nursing was to notify the physician and recheck Resident #19's glucose level on [DATE] at 5:03 PM, and stated she did not know why she had not done it as required. 4. Review of Resident #12's medical record revealed the facility admitted the resident on [DATE], with diagnoses including Diabetes Mellitus and Chronic Kidney Disease. Review of Resident #12's MDS assessment, dated [DATE], revealed the resident had a BIMS score of fifteen (15) which indicated the resident had been assessed to have no concerns with cognition. Review of Resident #12's Comprehensive Care Plan revised on [DATE], revealed interventions implemented to address the resident's Diabetes Mellitus included providing blood glucose monitoring as ordered, notifying the physician with significant changes, and observing for signs and symptoms of hypoglycemia. Review of the Physician's Orders for Resident #12, dated [DATE], revealed an order for staff to obtain the resident's blood glucose level before meals. In addition, the facility received an order on [DATE], for the resident to receive Novolog insulin 8 units subcutaneously before meals. Review of Resident #12's MARS for [DATE], revealed on [DATE] at 5:13 AM, the resident's blood glucose level was 61 mg/dl, and on [DATE] at 5:22 AM, the resident's blood glucose level was 64 mg/dl. However, there was no evidence the staff notified the physician of the resident's low blood glucose levels or that the glucose level was rechecked or monitored as required. Observation of Resident #12, on [DATE] at 11:30 AM, revealed the resident was observed to be sitting in his/her wheelchair in the resident's room. No signs or symptoms of hypoglycemia were observed. Interview conducted with Resident #12, on [DATE] at 11:35 AM, revealed the resident stated he/she had no concerns with the blood glucose monitoring provided to him/her by the facility. Interview with LPN #2, on [DATE] at 10:00 AM, revealed she was not aware of the facility's Hypoglycemia Management Algorithm, however, should have rechecked and monitored the resident's blood glucose level and provided the resident a snack. 5. Review of Resident #42's medical record, revealed the facility admitted the resident on [DATE], with diagnoses including Diabetes Mellitus and Chronic Kidney Disease. Review of Resident #42's MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15), which indicated the resident had been assessed to have no concerns with cognition. Review of Resident #42's Comprehensive Care Plan, revised on [DATE], revealed interventions implemented to manage the resident's Diabetes Mellitus included monitoring the resident's glucose levels, notifying the resident's physician of any significant changes in signs and symptoms, and observing for signs and symptoms of hypoglycemia. Review of physician orders for Resident #42, revealed an order dated [DATE], for staff to obtain the resident's blood glucose level before meals and at bedtime, and an order dated [DATE], for the resident to receive Tresiba insulin subcutaneously every morning. Review of Resident #42's MARS for [DATE], revealed on [DATE] at 4:40 PM, revealed the resident's blood glucose level was 64 mg/dl, [DATE] at 4:44 PM, the resident's blood glucose level was 64 mg/dl, and on [DATE] at 11:54 AM, the resident's blood glucose level was 57 mg/dl. However, there was no evidence the physician was notified or the resident's blood glucose level was rechecked or monitored as required. Observation of Resident #42, on [DATE] at 10:45 AM, revealed the resident was observed to be up in a wheelchair in his/her room. No signs or symptoms hypoglycemia observed. Interview conducted with Resident #42, on [DATE] at 10:50 AM, revealed the resident stated he/she had no concerns regarding the care he/she received by the facility. Interview with LPN #9 on [DATE] at 10:40 AM, revealed the LPN was aware of the facility's Hypoglycemia Management Algorithm and was aware that any time a resident was hypoglycemic she was required to notify the physician and recheck the blood glucose level. However, LPN #9 stated she failed to follow the facility's policy hypoglycemic management for Resident #42 on [DATE] at 4:40 PM, [DATE] at 4:44 PM, and on [DATE] at 11:54 AM, when the resident was hypoglycemic. The LPN stated she should have rechecked the blood glucose level after providing the resident a snack and notified the resident's physician. Interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, revealed the facility identified staff had not followed the Hypoglycemia Management Algorithm after Resident #250 was transferred to the hospital. However, according to the DON, she had not identified that staff did not follow the algorithm for Resident #7, Resident #19, Resident #12, nor Resident #42. The facility alleged the following was implemented to remove Immediate Jeopardy on [DATE]: 1. Education related to documentation of blood glucose checks, physician notification, and documentation of physician notification related to change in resident's condition was initiated on [DATE], and completed on [DATE] for all licensed nursing staff. 2. Residents at the facility with diagnosis of Diabetes Mellitus were assessed by the Director of Nursing (DON) by [DATE], for signs and symptoms of hyperglycemia/hypoglycemia. No concerns were identified. 3. Residents at the facility with diagnosis of Diabetes Mellitus had charts reviewed by the Signature Care Consultant (SCC), by [DATE]. The SCC looked for signs and symptoms of hypo/hyperglycemia for the last 30 days and the treatment plan for hypo/hyperglycemia was followed per physician order. Any issues from chart audits had physician and family notification on [DATE], by the DON or Administrator. No injury or harm was noted. 4. On [DATE], residents with BIMS score of eight (8) or above were asked the following questions by the Social Services Director (SSD) 1): Do the staff address your needs? 2.) If you have a concern or a medical problem, for example a low blood sugar, do the staff respond, notify your doctor and provide treatment if needed? 3.) Do you have any concerns related to your care at this time? No concerns were voiced. 5. On [DATE], residents (with BIMS score of less than eight) families were called and asked the following questions by the SW: 1.) Do you feel the staff address your family members needs appropriately? 2.) If your family member has a change in condition, are you and the physician notified? 3.) Do you have any concerns with your family members care? Any issues were addressed by the Administrator by [DATE]. 6. Residents with BIMS of less than eight (8) received an assessment for any signs or symptoms of a change in condition that had not been addressed on [DATE] by the DON and Restorative Nurse. No new concern were noted. 7. The SCC educated the Administrator, DON, MDS Coordinator and the Restorative Nurse on [DATE], regarding the signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, physician and family notification, completing SBAR, Accuchecks, Resident Rights and Abuse/Neglect. 8. All licensed nurses were educated on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, physician and family notification, completing SBAR, Accuchecks, Resident Rights, Abuse/Neglect, and the Hypoglycemia Management Algorithm. The training included appropriate steps to follow such as results received/steps such as management to include simple carbohydrate administration, rechecking of glucose levels and when to notify MD with action to take when new orders were received. This training was initiated by the DON, Restorative Nurse, MDS Coordinator and Administrator, on [DATE]. Education would continue prior to staff working their next scheduled shift by [DATE]. Licensed Nurse staff who were as needed, on FMLA or on leave would be issued a certified letter by Administrator with return receipt on [DATE], alerting them that they must receive an education on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, completing SBAR and Accucheck competency completed prior to their first shift back to work. A pre-post test would be given in which a passing score of 100% must be obtained on the post test. If 100% not obtained the staff member would be re-educated and a post test would be reissued. 9. All State Registered Nurse Aides (SRNA) and all other facility staff would be provided education on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect was initiated by the DON, MDS Coordinator, Restorative Nurse and Administrator on [DATE]. Education would continue prior to staff working their next scheduled shift by [DATE]. SRNAs and all other facility staff who are PRN, on FLMA or on leave would be issued a certified letter by Administrator with return receipt on [DATE] alerting them that they must receive education on signs and symptoms of hypo/hyperglycemia, how to care for a resident with Diabetes Mellitus, licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect completed prior to their first shift back to work. A pre-post

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure licensed nursing staff had the knowledge and competency to provide care for residents that require blood glucose monitoring and the implementation of the facility's Hypoglycemia Management Algorithm, for five (5) of eighteen (18) sampled residents (Resident #250, Resident #7, Resident #19, Resident #12, and Resident #42). Record review and interviews revealed, on 08/06/2020, Resident #250's fingerstick blood glucose level was 66 (ADA recommendation range for someone with diabetes: 80-130 mg/dl) at 5:09 PM and was 59 at 8:15 PM. On 08/07/2020 at 5:09 PM, the resident had a blood glucose level of 46. Approximately, four (4) hours hours later at 9:19 PM, the resident's blood glucose level was 37. Resident #250 requested to be sent to the hospital, on 08/07/2020 at 9:30 PM. Review of the ambulance documentation for Resident #250, dated 08/07/2020 at 10:51 PM, when they arrived at the facility, the resident was unresponsive with snoring respirations and had a blood glucose level of 34. The resident was transported to the acute care hospital where he/she required intravenous fluids and medication to maintain his/her blood sugar. Further record review and interviews, revealed the facility utilized a Hypoglycemia Management Algorithm, which required staff to notify the resident's physician for blood glucose levels (blood sugar) less than 70, and continue to monitor blood glucose levels, after fifteen minutes and offer simple carbohydrates. Licensed Practical Nurse (LPN) #1, #2, #3, and #7 provided care for Resident #250, on 08/06/2020 and 08/07/2020, and checked the resident's blood glucose. The LPN's documented during their shift that the resident's blood glucose was less that 70. However, there was no evidence the LPN's took appropriate action to address the resident's Hypoglycemia, as required by the facility's algorithm. Interviews with Licensed Practical Nurse (LPN) #1 and LPN #3, revealed both nurses had been employed by the facility approximately three (3) weeks (around the first week of August 2020). However, neither had been educated on the facility's Hypoglycemia Algorithm, nor had their competency evaluated related to the implementation of Hypoglycemia Management Algorithm. Further interviews revealed, LPN #2, who had been employed by the facility for five (5) years, and LPN #7, who had been employed two (2) years, stated they were also not aware of the facility Hypoglycemia Algorithm; nor had been evaluated by the facility for competency related to the implementation of the algorithm. In addition, licensed nursing staff failed to notify the resident's physician per the facility's protocol when Resident #7, Resident #19, Resident #12, and Resident #42 had blood glucose levels less than 70. The facility's failure to ensure licensed nurses were knowledgeable and competent has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/17/2020 and determined to exist on 08/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726). The facility was notified of the Immediate Jeopardy on 09/17/2020. An acceptable Allegation of Compliance was received on 09/23/2020, which alleged removal of Immediate Jeopardy on 09/22/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 09/22/2020 as alleged, prior to exit on 10/01/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of a policy titled,Blood Glucose Monitoring, with a review date of 05/24/18, revealed upon a diagnosis of hypoglycemia, the critically low glucose levels shall be treated per facility policy for treatment of hypoglycemia. A review of a protocol titled,Hypoglycemia Management Algorithm, with a revision date of 09/01/2015, utilized by the facility and developed by the American Diabetes Association, revealed staff were required to notify a resident's physician for blood glucose levels (blood sugar) less than seventy (70). The protocol also revealed if the resident was awake and able to swallow a simple carbohydrate such as juice, regular soda, milk, hard piece of candy, glucose gel, or glucose tablets would be administered. Per the protocol, the blood glucose level would be rechecked after fifteen (15) minutes. The protocol revealed if the blood glucose level was not greater than or equal to seventy (70) the physician would be notified again for further direction. The protocol stated if the blood glucose level was greater than or equal to seventy (70) then a protein or nutrious snack such as yogurt would be administered. Interview with the Director of Nursing (DON), on 09/17/2020 at 2:30 PM, revealed the facility did not have a policy related to staff competency or orientation training. The DON stated all new nurses were required to attend orientation and would work with another nurse for approximately two (2) weeks or longer if needed. The DON stated all nurses received an annual competency checklist completed as well. 1. Review of Resident #250's closed medical record, revealed the facility admitted the resident on 08/05/2020, with diagnoses of Type II Diabetes Mellitus, Hypertension, Malignant Neoplasm of Breast, Mastectomy with Breast Reconstruction. Review of Resident #250's Baseline admission Care Plan, undated, revealed the facility identified that the resident had a diagnosis of diabetes. The facility-developed goal was for the resident to not develop complications, and with interventions to continue medications and blood sugars as ordered. Review of Resident #250's Physician Orders (PO), dated 08/05/2020, revealed the resident had an order for staff to obtain the resident's blood sugar before meals and at bedtime. Review of the Medication Administration Record (MAR) for Resident #250, revealed on 08/06/2020 at 5:09 PM, revealed LPN #7 documented the resident had a blood glucose level of 66. Interview conducted with LPN #7, on 09/16/2020 at 8:46 AM, revealed she had been employed by the facility for two (2) years. The LPN revealed she had completed the blood glucose monitoring for Resident #250, on 08/06/2020 at 5:00 PM, when the level was documented as being 66. The LPN stated she had done nothing because she knew the resident would be receiving a supper meal tray. The LPN stated she did not repeat the blood glucose monitoring nor did she notify the physician and should have. The LPN stated she had not been aware of the facility protocol (Hypoglycemia Management Algorithm) for hypoglycemia until after the inservice on 08/11/2020. The LPN stated she should have repeated the blood glucose monitoring and should have notified the physician. In addition, the MAR revealed, on 08/06/2020 at 8:15 PM, revealed LPN #3 assessed Resident #250's blood glucose level to be 59. Continued review of the MAR, revealed on 08/07/2020 at 6:00 AM, there was no evidence blood glucose monitoring was completed per the facility policy/protocol or Physician Order. Interview conducted with LPN #3, on 09/15/2020 at 5:45 PM, revealed she had been employed for three (3) weeks when she was responsible for conducting the blood glucose monitoring for Resident #250, on 08/06/2020 at 8:15 PM, and 08/07/2020 at 6:00 AM, which had been missed, and on 08/07/2020 at 9:19 PM. The LPN stated she was unsure but probably had completed Resident #1's blood glucose monitoring, on 08/07/2020 at 6:00 AM, but could not recall the level. Interview with Licensed Practical Nurse (LPN) #1, on 09/14/2020 at 6:25 PM, revealed she had only been employed by the facility for three (3) weeks when, on 08/07/2020 at 12:26 PM, she checked Resident #250's blood glucose level and it was 56. LPN #1 stated she notified the resident's physician and gave the resident orange juice. The LPN stated she had observed the resident to eat his/her lunch meal tray. However, she did not recheck the resident's blood glucose level and was not aware she should have. The LPN stated the physician had come to the facility and had saw the resident on 08/07/2020. The LPN stated Resident #250's blood glucose level on 08/07/2020 at 5:09 PM, was 46. The LPN stated she had given the resident a cup of orange juice and asked him/her if he/she would like a peanut butter sandwich; however, the resident declined the peanut butter sandwich. The LPN stated she did not recheck the resident's blood glucose level nor did she notify the resident's physician. The LPN stated no one at the facility had observed her performing blood glucose monitoring nor had she completed a competency evaluation. The LPN stated she had been in orientation for two (2) weeks and was only working two (2) days per week. The LPN stated she was not aware of the Hypoglycemia Management Algorithm protocol nor had she been instructed by the facility on what to do if a resident had a low blood glucose level. Further review of the MAR revealed, on 08/07/2020 at 5:09 PM, the resident's blood glucose level was 46 with no evidence the physician was notified or the blood glucose was recheck in fifteen minutes per the protocol; on 08/07/2020 at 9:19 PM, the resident had a thirty seven (37) documented blood glucose level. A review of Resident #250's Nurses Notes, revealed no evidence the resident's physician was notified of low blood glucose levels for the resident, until 08/07/2020 at 2:27 PM, when the resident's physician physically visited the resident and wrote a physician's order to discontinue administration of Amaryl four (4) mg daily orally (to lower blood glucose level). The next mention of physician notification related to the resident's blood glucose levels was on 08/07/2020 at 9:30 PM. The nurses notes further revealed, on 08/07/2020 at 9:30 PM, Resident #1's physician was notified due to the resident having a blood glucose level of thirty seven (37), and a new order was received to administer Glucose Gel (to raise blood glucose level) orally now and to discontinue both Metformin one thousand (1000) mg twice daily orally (to lower blood glucose level) and Januvia one hundred (100) mg daily orally (to lower blood glucose level). Continued review of the Nurses Notes, revealed at 9:30 PM on 08/07/2020, Licensed Practical Nurse (LPN) #3, administered Glucose Gel (to raise blood glucose level), and the resident requested to be transferred to the hospital. The nurse documented she notified the resident's physician and arrangements were made to transfer the resident to the hospital. The nurses's notes revealed the resident's blood glucose level was rechecked after he/she was administered Glucose Gel (to raise blood glucose level). However, no time was documented when the blood glucose level was obtained. The results were documented as being 85 and the resident was documented as being lethargic and very difficult to arouse. Further, review revealed no evidence of continued resident monitoring. The nurses notes revealed the ambulance service arrived at the facility, on 08/07/2020 at 10:27 PM, and departed from the facility to the hospital, on 08/07/2020 at 10:34 PM. A review of the Ambulance Service documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed they assessed the resident to be unresponsive with snoring respirations and the resident's blood glucose level as being 34. The ambulance record revealed an intravenous line was obtained and 50% Dextrose 25 mg intravenously (used to increase blood glucose level) was administered. The ambulance record revealed the resident opened his/her eyes and was able to nod answers to questions. The ambulance record revealed a second 50% Dextrose 25 mg intravenously was administered and then the resident was able to speak in sentences and move his/her extremities independently. The ambulance documentation revealed the resident was then transferred to the acute care hospital. A review of the Acute Care Hospital record for Resident #250, revealed the resident arrived at the hospital, on 08/07/2020 at 11:35 PM. The hospital medical record revealed the resident received a D5W intravenous drip. On 08/07/2020 at 11:45 PM, a blood glucose level of sixty nine (69) was documented and 50% Dextrose 25 mg was administered intravenously. The acute care hospital record further revealed on 08/08/2020 at 1:45 AM, the resident's blood glucose level was documented as being less than 60 and an additional 50% Dextrose 25 mg was administered. The acute care hospital record revealed the resident was admitted by the acute care hospital, on 08/08/2020 at 4:19 AM, with a diagnoses of Type 2 Diabetes Mellitus with Hypoglycemia. Interview with LPN #2, on 09/14/2020 at 6:51 PM, revealed she had helped LPN #3 on 08/07/2020 at 9:19 PM, when Resident #250's blood glucose level was 37. The LPN stated she had told LPN #3, to notify Resident #250's physician. LPN #2 stated LPN #3 had administered Glucagel (to raise blood glucose level) and had rechecked the blood glucose level and it was 85. The LPN stated she had assisted LPN #3 with the resident until the resident was sent out of the facility to the acute care hospital. The LPN stated she had been employed by the facility for five (5) years, and had not been aware of the facility protocol (Hypoglycemia Management Algorithm). Continued interview on 09/15/2020 at 5:45 PM, with LPN #3, revealed she was not aware of the facility protocol (Hypoglycemia Management Algorithm) on 08/06/2020 and 08/07/2020. The LPN stated no one had ever watched her do blood glucose monitoring. The LPN stated she had notified the physician when Resident #1 had a blood glucose level of 37, had administered Glucogel (to raise blood glucose level), and had made arrangements and transferred the resident to the acute care hospital. The LPN stated she had rechecked the resident's blood glucose level after administering the Glucogel (to raise blood glucose level) and it was 85 at that time but could not recall the exact time. The LPN stated she was unsure but probably had completed Resident #1's blood glucose monitoring, on 08/07/2020 at 6:00 AM, but could not recall the level. The LPN stated she had been in orientation with another nurse for two (2) weeks. Review of facility staff education records revealed the facility conducted annual inservices on 11/01/2019. Further review revealed staff completed a Medication Administration Skills Checklist and a Nurse Competency Skills Checklist upon hire and annually that included blood glucose monitoring which had been attended by LPN #2 and LPN #7. The competency checklists had been completed and signed by the Administrator dated 11/01/19. Review of the facility staff education records for LPN #1 and LPN #3, revealed the nurses had a Medication Administration Skills Checklist and a Nurse Competency Skills Checklist that included blood glucose monitoring, which had been completed for them by the DON, on 07/15/2020. Further review of the checklist/competency, revealed the nurse was checked off related to calling the physician if the resident's blood glucose level was high or low. However, review of the checklists, revealed the the blood glucose monitoring did not evaluate the nurse's knowledge/competency as to treating and assessing a resident with signs/symptoms of hypoglycemia. 2. A review of Resident #7's medical record, revealed the facility admitted the resident on 04/10/19, with diagnoses which include Type 2 Diabetes Mellitus, and Stage IV Kidney Disease. A review of Resident #7's physician's orders, revealed an order dated 05/30/2020, for the resident to have blood glucose monitoring before meals and at bedtime. The physicians orders also revealed orders, dated 07/08/2020, for the resident to receive Lantus six (6) unit subcutaneous daily (insulin to lower blood glucose level); and Novolin R five (5) units subcutaneous before meals (to lower blood glucose level). A review of Resident #7's Quarterly Minimum Data Set (MDS) assessment, dated 07/08/2020, revealed the resident had a diagnosis of Diabetes Mellitus. The MDS assessment further revealed the resident had received insulin (to lower blood glucose level) injections. A review of Resident #7's Comprehensive Care Plan with a review date of 07/14/2020, revealed interventions were developed to perform blood glucose monitoring as ordered; and to observe for and report signs and symptoms of hypoglycemia. A review of Resident #7's MARS, revealed blood glucose monitoring on 08/31/2020 at 4:40 PM at a level of 64; 09/03/2020 at 5:08 PM at a level of 63; on 09/08/2020 at 8:08 PM at a level of 65. Review of the Nurse's Notes, revealed no evidence the resident's physician was notified of the resident's low (less than 70) blood glucose levels on 08/31/2020, 09/03/2020 or 09/08/2020. Interview with Registered Nurse (RN) #2, on 09/16/2020 at 8:20 AM, revealed she was responsible for performing blood glucose monitoring for Resident #7, on 09/08/2020 at 8:08 PM. The RN stated she was aware of the facility's Hypoglycemia Management Algorithm, but had not notified the physician, since she felt she could take care of the low level herself. The RN further stated she had not rechecked the blood glucose level for the resident. The RN stated she had given the resident a peanut butter sandwich and a cup of orange juice. The RN stated she attended annual inservices on blood glucose monitoring. The RN stated she had to provide a return demonstration on how to perform the testing but could not recall if hypoglycemia was discussed. Per the RN, an outcome of staff not reassessing resident after a low blood glucose level, was the resident could go into a diabetic coma. Interview conducted with LPN #7, on 09/17/2020 at 10:50 AM, revealed she was responsible for completing the blood glucose monitoring for Resident #7, on 09/03/2020 at 5:08 PM. The LPN stated she had not notified the physician nor had she repeated the blood glucose monitoring and guessed she probably should have. The LPN stated she was not aware of the facility protocol for treating hypoglycemia. The LPN stated nurses including herself were in orientation approximately two (2) weeks. The LPN stated she was required to attend an annual orientation on blood glucose monitoring and had to provide a return demonstration of how to perform the testing. However, the LPN stated she had not been educated on what to do if blood glucose levels were too low. The LPN stated she had been a mentor for LPN #1. Interview with LPN #6, on 09/17/2020 at 1:30 PM, revealed she was responsible for completing the blood glucose monitoring for Resident #7, on 08/31/2020 at 4:40 PM. The LPN stated she had not repeated the resident's blood glucose monitoring, nor had she notified the resident's physician, but should have. The LPN stated she was unaware of the facility protocol for treating Hypoglycemia. The LPN stated she was required to attend an annual inservice and had to provide a return demonstration on how to perform blood glucose monitoring. The LPN stated the inservice did not address what to do if a blood glucose level was too low. The LPN further stated if a resident had a blood glucose level of less than sixty, she would notify the physician and recheck the level after providing a snack. The LPN stated she thought the resident was alright because his/her blood glucose level was not below sixty (60). 3. A review of the medical record for Resident #19, revealed the facility admitted the resident on 12/17/19, with diagnoses which included Type 2 Diabetes Mellitus, Atrial Fibrillation, and Anxiety. A review of the Physician's Orders for Resident #19, revealed an order dated 08/24/2020, for the resident to have blood glucose monitoring before meals. Further review revealed an order dated 09/02/2020, for the resident to receive Novolin R Regular U-100 Insulin (to lower blood glucose levels) twelve (12) units subcutaneous after breakfast and lunch. If the resident does not eat a lot only administer one half the dose; Novolin R Regular U-100 Insulin (to lower blood glucose level) eight (8) units subcutaneous after the evening meal, if the resident does not eat a lot only administer one half the dose. A review of the Quarterly MDS assessment for Resident #19, dated 08/27/2020, revealed the resident had a diagnosis of Diabetes Mellitus and received insulin (to lower blood glucose levels) injections daily. A review of Resident #19's Comprehensive Care Plan, with a revision date of 09/02/2020, revealed interventions had been developed for the resident to receive a Glucagon (to increase blood glucose levels) injection if the resident's blood glucose level was less than 60, and had difficulty responding; provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of hypoglycemia. A review of the MAR for Resident #19, revealed on 09/06/2020 at 5:03 PM, the blood glucose level was documented as being 64, and no insulin (to lower blood glucose level) was administered. There was no evidence the physician was notified or the blood glucose monitoring was repeated. Interview with LPN #9, on 09/17/2020 at 10:40 AM, revealed the LPN was aware of the facility protocol (Hypoglycemia Management Algorithm). The LPN stated she was aware she was required to notify the physician and repeat the blood glucose monitoring for Resident #19 on 09/06/2020 at 5:03 PM. The LPN stated she did not know why she had not but should have. The LPN stated she had been trained on the Hypoglycemia Management Algorithmand also received an annual inservice on blood glucose monitoring in which a return demonstration was required. 4. A review of Resident #12's medical record, revealed the facility admitted the resident on 05/13/2020, with diagnoses which include Type 2 Diabetes Mellitus and Chronic Kidney Disease Stage III. A review of the Physician's Orders for Resident #12, revealed an order dated 05/25/2020, for the resident to receive blood glucose monitoring before meals; and an order dated 06/5/2020, for the resident to receive Novolog U-100 (to lower blood glucose levels) eight (8) units subcutaneous before meals. A review of the Quarterly MDS assessment for Resident #12, dated 08/12/2020, revealed the resident had a diagnosis of Diabetes Mellitus and received insulin (to lower blood glucose levels) injections daily. A review of Resident #12's Comprehensive Care Plan with a revision date of 08/14/2020, revealed interventions developed to provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of hypoglycemia. A review of the MAR for Resident #12 revealed, on 09/03/2020 at 5:13 AM, the blood glucose was documented as being 61; and on 09/09/2020 at 5:22 AM, the blood glucose was documented as being 64. There was no evidence the physician was notified or the blood glucose monitoring were repeated. Interview with LPN #2, on 09/17/2020 at 10:00 AM, revealed she had not been aware of the facility protocol for Hypoglycemia. The LPN stated she should have repeated the blood glucose monitoring, provided a snack and should have notified the resident's physician. The LPN stated she was unsure why she had not. 5. A review of Resident #42's medical record, revealed the facility admitted the resident on 09/25/19, with diagnoses which included Type 2 Diabetes Mellitus and Chronic Kidney Disease Stage III. A review of the Physician's Orders for Resident #42, revealed an order dated 11/04/19, for blood glucose monitoring to be completed before meals and at bedtime; and an order dated 04/24/2020, for the resident to receive Tresiba U-100 (to lower blood glucose level) one hundred sixty four (164) units subcutaneously every morning. A review Resident #42's Annual MDS Assessment, dated 09/08/2020, revealed the resident had a diagnosis of Diabetes Mellitus and received insulin (to lower blood glucose levels) injections daily. A review of Resident #42's Comprehensive Care Plan, with a revision date of 09/11/2020, revealed interventions developed to provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of hypoglycemia. A review of the MAR for Resident #42, for 08/20/2020 at 4:40 PM, revealed the blood glucose was documented as being 64; on 08/22/2020 at 4:44 PM, the blood glucose was documented as being 64; on 09/03/2020 at 11:54 AM, the blood glucose was documented as being 57. There was no evidence the physician was notified or the blood glucose monitoring was repeated. Interview conducted with LPN #9, on 09/17/2020 at 10:40 AM, revealed the LPN was aware of the facility Hypoglycemia Management Algorithm. The LPN stated she was aware that she was required to notify the physician and repeat the blood glucose monitoring for Resident #42, on 08/20/2020 at 4:40 PM; on 08/22/2020 at 4:44 PM; and on 09/03/2020 at 11:54 AM. The LPN stated she should have rechecked the blood glucose monitoring after providing a snack and notification of the physician. Review of an inservice roster titled, Diabetic Care, dated 08/11/2020, revealed nurses had attended an inservice on diabetic care and had received policies related to diabetic care. However, there was no evidence the facility had evaluated the effectiveness of the training or checked the competency of the nurses after the training. Interview with LPN #6, on 09/17/2020 at 1:30 PM, LPN #7 on 09/17/2020 at 10:50 AM, LPN #1 on 09/14/2020 at 6:25 PM, and LPN #2 on 09/17/2020 at 10:00 AM, revealed they were not aware of the facility protocol for the management of hypoglycemia. In addition, interview with LPN #9, on 09/17/2020 at 10:40 AM, and Registered Nurse (RN) #2, on 09/16/2020 at 8:20 AM, revealed both had been aware of the facility protocol for managing hypoglycemia but had failed to follow the protocol. As noted above, LPN #9 failed to follow the protocol related to physician notification, on 08/20/2020, 08/22/2020, 09/03/2020 and 09/06/2020 and RN #2 failed to follow the protocol on 09/08/2020. Interview with the Director of Nursing (DON), on 09/17/2020 at 2:30 PM, revealed upon hire all nurses were placed in orientation for two (2) weeks with another nurse. The DON stated nurses were required to attend orientation on the computer for the first three (3) days of employment, from 9:00 AM to 1:00 PM. The DON stated the new nurse would then be placed with another more experienced nurse who would be responsible for completing the nurses competency checklist of which blood glucose monitoring was included. The DON stated she had provided an inservice on 08/11/2020, for the facility nurses on diabetic care which included blood glucose monitoring and the use of the Hypoglycemia Management Algorithm. The DON stated she had required the nurses to provide a return demonstration which included the nurse performing a fingerstick blood glucose. The DON stated she ensured nurses knew they were to call the physician for a blood glucose level of 70 or below. However, the DON stated she had no documentation on the return demonstration or of any evaluation of the nurse's understanding of the training. Further interview with the DON, revealed nurses were required to utilize the Hypoglycemia Management Algorithm anytime a resident had a blood glucose level of seventy (70) or lower. The DON stated she had been monitoring residents who received blood glucose monitoring daily, during rounds and during the interdisciplinary Team (IDT) Meetings, which were held daily Monday through Friday. The DON stated she monitored to ensure staff provided residents with appropriate blood glucose monitoring (per the facility protocol) and she had not identified any further care issues, after the incident with Resident #250. The DON stated she had not identified the blood glucose levels that were less than 70 (as noted above) for Resident #7, #12, #19 and #42, nor had she identified that nursing staff had not implemented the Hypoglycemia protocol/algorithm. In addition, the DON stated she was responsible for providing inservice training for all staff, as the facility currently did not have a Staff Development Coordinator (SDC). The DON revealed she had only been in her new position, for two (2) weeks, and was responsible for ensuring orientation and the competency checklists were completed. The DON stated she had completed the Medication Administration Skills Checklist and a Nurse Competency Skills Checklist which included competency related to glucose monitoring for LPN #1 and LPN #3. However, the skills checklists did not include all requirements of the algorithm, and only assessed the nurses knowledge to call the physician for high or low blood glucose levels. Interview with the Administrator, on 09/17/2020 at 3:00 PM PM, revealed staff were required to use the Hypoglycemia Management Algorithm for any resident who had a blood glucose level of seventy (70) or less. The Administrator stated all nurses were in orientation at least two (2) weeks and were required to have competency checklist completed of which blood glucose monitoring was included. The Administrator stated the nurses were also required to have an annual inservice with competency checklists completed. The Administrator stated she had completed the Medication Administration Skills Checklist and a Nurse Competency Skills Checklist, for LPN #2 and LPN #7, on 11/01/19 (Administrator is a nurse). The Administrator stated the checklist included competency with glucose monitoring but did not include the specifics in the algorithm and only assessed that the nurse knew to call the physician for high or low blood glucose levels . The facility alleged the following was implemented to remove Immediate Jeopardy on 09/22/2020: 1. Education related to documentation of blood glucose checks, physician notification, and documentation of physician notification related to change in resident's condition was initiated on 08/11/2020, and completed on 08/14/2020 for all licensed nursing staff. 2. Residents at the facility with diagnosis of Diabetes Mellitus were assessed by the Director of Nursing (DON) by 09/18/2020, for signs and symptoms of hyperglycemia/hypoglycemia. No concerns were identified. 3. Residents at the facility with diagnosis of Diabetes Mellitus had charts reviewed by the Signature Care Consultant (SCC), by 09/18/2020. The SCC looked for signs and symptoms of hypo/hyperglycemia for the last 30 days and the treatment plan for hypo/hyperglycemia was followed per physician order. Any issues from chart audits had physician and family notification on 09/21/2020, by the DON or Administrator. No injury or harm was noted. 4. On 09/18/2020, residents with BIMS score of eight (8) or above were asked the following questions by the Social Services Director (SSD) 1): Do the staff address your needs? 2.) If you have a concern or a medical problem, for example a low blood sugar, do the staff respond, notify your doctor and provide treatment if needed? 3.) Do you have any concerns related to your care at this time? No concerns were voiced. 5. On 09/18/2020, residents (with BIMS score of less than eight) families were called and asked the following questions by the SW: 1.) Do you feel the staff address your family members needs appropriately? 2.) If your family member has a change in condition, are you and the physician notified? 3.) Do you have any concerns with your family members care? Any issues were addressed by the Administrator by 09/21/2020. 6. Residents with BIMS of less than eight (8) received an as[TRUNCATED]