Based on record review, observation, and staff and Medical Director interviews, the facility failed to ensure nursing staff were competent in following manufacturer's guidelines for cleaning and disinfecting a shared glucometer when Nurse #1 was observed not disinfecting a shared glucometer (Resident #35). Also, Medication Aide #1 (an agency staff member) failed to clean and disinfect an individually assigned glucometer using the approved disinfectant wipes according to manufacturer's recommendations for Resident #32 who was observed having a blood glucose level checked. This occurred for 2 of 7 nursing staff members (Nurse #1 and Medication Aide #1) reviewed for competency. Immediate jeopardy began on 2/17/25 when Nurse #1 failed to demonstrate competency through her failure to disinfect a shared glucometer per manufacturer's instructions. Immediate jeopardy was removed on 2/19/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for finding #2 and for the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place. The findings included: 1. The skills validation record for Nurse #1 dated 5/7/2024 included the use of equipment that included glucometers. The former Assistant Director of Nursing signed the validation form on 5/7/2024. An educational in-service roster dated 9/11/2024 and 9/12/2024 on cleaning glucometers between patients every time for infection control practices stated to allow the glucometer to air dry 2 minutes after wiping with purple wipes and place on a clean surface to dry. Nurse #1's signature was not included on the roster to indicate she had received the education. On 2/17/2025 at 5:50 am in preparation to check Resident #35's blood glucose, Nurse #1 was observed searching for Resident #35's glucometer. Nurse #1 stated each resident had their individually assigned glucometer to check blood glucose levels. Nurse #1 was observed opening the top drawer of the 100-hall medication cart flipping three glucometer pouches labeled with Resident #66's, Resident #33's and Resident # 93's name and room number upward toward Nurse #1. Nurse #1 was observed locking the 100-hall medication cart and walking to the 200-hall medication cart before returning to the 100-hall medication cart and reopening the top drawer. Nurse #1 reflipped Resident #66's, Resident #33's and Resident # 93's labeled glucometer pouches upward toward her and picked up Resident #33's glucometer pouch. There was an unlabeled glucometer not in a labeled glucometer pouch observed underneath Resident #33's glucometer pouch. Nurse #1 stated the unlabeled glucometer was Resident #35's glucometer and was observed not disinfecting the glucometer before performing a blood glucose test on Resident #35 on 2/17/2025 at 5:56 am. Nurse #1 was observed returning the used unlabeled glucometer to the top drawer of the 100-hall medication cart without disinfecting the glucometer. On 2/17/2025 at 6:00 am in an interview with Nurse #1, she stated Resident #35 did not have a labeled glucometer pouch and the reason she did not disinfect the glucometer before performing the blood glucose was because the staff member who used the glucometer before she used it should have disinfected the glucometer. Nurse #1 stated she did not think about disinfecting the glucometer after performing the blood glucose test. Nurse #1 was observed removing an alcohol pad from the top drawer of the 100-hall medication cart and wiping the unlabeled glucometer without an resident identified glucometer pouch with the alcohol pad and returning the unlabeled glucometer to the top drawer of the 100-hall medication cart. She stated she always disinfected glucometers with alcohol pads and Resident #35 was the only blood glucose monitoring she had to perform. In an interview with Nurse #2 on 2/18/2025 at 10:08 am, she identified the unlabeled / unidentified glucometer not stored in a pouch with a resident's name and room number as a shared glucometer. She stated the Resident #35 and Resident #31 who resided on the 100 hall did not have individually assigned glucometers and shared the unlabeled / unidentified glucometer. She also stated a disinfectant wipe was used to clean glucometers after each use on a resident. On 2/18/2025 at 10:42 am in a follow up phone interview with Nurse #1, she stated she thought the unlabeled glucometer that was not in a pouch labeled with a resident's name and room number on the 100-hall medication cart was Resident #35's glucometer on 2/17/2025 when performing the blood glucose monitoring. She stated Resident #31 also received blood glucose monitoring and did not have an individually assigned glucometer, and she had forgotten Resident #35 and Resident #31 shared the unlabeled glucometer not in a labeled pouch. Nurse #1 stated she was trained on how to use and disinfect a glucometer with employment orientation and was unable to recall the instructions on how to use the disinfectant wipes at the facility. She reported there were no disinfectant wipes on the 100-hall medication cart to clean the glucometer on the morning of 2/17/2025. On 2/17/2025 at 6:50 am in an interview with the Director of Nursing (DON), she stated the facility did not have a glucometer for every resident receiving blood glucose monitoring, and some of the glucometers on the medication carts were shared between residents. The DON stated Nurse #1 was to clean the glucometer that was shared between residents with the facility's EPA-disinfected wipes and allow the glucometer to dry for two minutes before storing in the resident's labeled glucometer pouch. The DON stated since starting at the facility five weeks ago, she had seen documentation that the nursing staff had received an educational in-services on cleaning and disinfecting glucometers. There was no documentation provided by the facility that recorded educational in-services were conducted on cleaning and disinfecting glucometers since 9/12/2024. The facility's Administrator was informed of the immediate jeopardy (IJ) on 2/18/2025 at 2:00 pm. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to ensure Nurse #1 was trained and competent in following manufacturer's guidelines for cleaning and disinfecting a shared glucometer and on knowing how to distinguish an individually assigned resident glucometer from a shared glucometer. Nurse #1 failed to ensure an unlabeled / unidentified glucometer that was shared between Resident #35 and Resident #31 on the 100-hall medication cart was cleaned and disinfected prior to and after use. (Resident #35) Nurse #1 thought the glucometer was individually assigned to Resident #35 and had forgotten that the unlabeled / unidentified glucometer was also used on Resident #31. Nurse #1 indicated the glucometer used for Resident #35 was individually assigned. She stated she did not think about cleaning and disinfecting the unlabeled / unidentified glucometer after performing Resident #35's blood glucose and stated she always cleaned residents' glucometer with alcohol wipes. The Director of Nursing stated the facility did not have a glucometer for every resident receiving blood glucose monitoring and some of the glucometers on the medication carts were shared between residents. The DON stated glucometers were to be cleansed with an approved disinfectant. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an EPA-registered disinfectant in accordance with the manufacturer's instructions to disinfect a shared glucometer potentially exposes residents to the spread of blood borne infections. Six residents within the facility were identified as having a diagnosis which included one or more blood borne pathogens. Nurse # 1 was removed from the schedule on 2/17/2025 and will be educated with a competency prior to returning to work. This will be completed by the Director of Nursing. Current residents that receive finger stick blood sugar checks are at risk. Forty residents require FSBS and all forty have been provided their individual glucometer. The Assistant Director of Nursing completed an audit on 2/18/2025. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Current residents who require finger stick blood sugars received their own individual glucometers and they were labeled and placed in an individual container. The was completed by the Director of Nursing and the Assistant Director of Nursing on 2/18/2025. Education was started by the Director of Nursing on 2/18/2025 to current licensed nursing staff, including agency staff, on proper procedure for cleaning glucometers and for proper storage of glucometers. Employees not receiving this education will not be allowed to work until the education is received. The Director of Nursing will track the education to ensure that current staff have received. Education includes each resident who receives a finger stick blood sugar will have an individual glucometer that is labeled with their name and stored in an individual container inside the med cart. Education also includes the proper cleaning technique as recommended by the manufacturer guidelines. The cleaning product will be kept on each medication cart. The Director of Nursing or charge nurse will check the med carts daily to ensure that the cleaning product is present on each med cart. The Director of Nursing educated the charge nurses on 2/18/2025. The Director of Nursing was educated on this process by the Administrator on 2/18/2025. Current Licensed Nurses will complete a skills return demonstration on glucometer cleaning and storage. This will be completed by the Director of Nursing. Any licensed nurse will not be allowed to work until return demonstration has been completed. The Director of Nursing will track the education to ensure that current staff have received. The Director of Nursing or charge nurse is responsible for ensuring new admissions who require finger stick blood sugars are provided with their own individual glucometer that is labeled with their name and stored in an individual container. The Director of Nursing was educated on this process by the Administrator on 2/18/2025. The charge nurses are educated on this process by the Director of Nursing on 02/18/2025. New licensed nurses will receive this education and verify competencies during the orientation process by the Director of Nursing or charge nurse. Agency nurses will receive this education and competencies prior to the start of their shift. The charge nurses were educated on this responsibility by the Director of Nursing on 02/18/2025. The Director of Nursing will assign the charge nurse to complete this task when needed. Immediate Jeopardy removal date 2/19/2025. The facility's credible allegation of immediate jeopardy removal was validated on 2/22/25. A phone interview with the medical director on 2/18/2025 validated the facility had notified the physician of the deficient practice and the facility was implementing new practices that included an individual glucometer per resident and educating the nursing staff on how to disinfect the glucometer after use on a resident. Observation of the 43 residents' (40 plus 3 admissions since 2/18/2025) individually assigned glucometers who currently resided in the facility on 2/22/2025 validated each resident receiving blood glucose monitoring had an individually assigned glucometer in a glucometer pouch labeled with their name and room number. Medication aides reported during interviews that blood glucose monitoring was performed by licensed nursing staff in the facility and medications aides did not conduct blood glucose monitoring in the facility. Interviews with licensed nursing staff on each hallway and on all shifts validated in-service training was conducted in regard to the use of individually assigned glucometers for resident blood glucose monitoring and the infection control practices for the disinfection of glucometers. All licensed nursing staff who were interviewed reported they had received the required in-service training on 2/18/2025 or prior to beginning their next assigned shift after 2/18/2025. The educational in-services stressed using individually assigned glucometers for each resident requiring blood glucose monitoring and storing each individual assigned glucometer in an individually labeled glucometer pouch with resident's name and room number. The in-service training also included a review of the manufacturer's instructions for the facility's glucometers and disinfectant wipes related to disinfection of the glucometer and completion of a returned demonstration of the proper procedure for effective glucometer disinfection. Nurse observation in conducting a blood glucose check and subsequent glucometer disinfection completed the task without difficulty. Individually assigned resident glucometers were observed stored on the medication carts in closed labeled pouches with resident's name and room number. Each medication cart was observed with a canister of EPA disinfectant wipes. The nursing staff were recording verification of individually assigned glucometers and EPA disinfectant wipes on each medication cart at the change of shift. There was an unused unlabeled new glucometer observed on each medication cart that licensed nursing staff validated through interviews the new unused glucometers were available for new admissions, replacement of a resident's individually assigned glucometer or in an emergency as needed. To prevent the likelihood of a new glucometer used as a shared glucometer, the facility removed the new, unused glucometers from each medication cart and relocated the storage of the new unused glucometer into the medication storage rooms on each unit. There were no further concerns identified during either the interviews or observations. The immediate jeopardy removal date of 2/19/25 was validated. 2. The manufacturer's operator manual revised 10/2019 for Resident #32's assigned glucometer provided instructions for cleaning and disinfecting the glucometer used at the facility. It stated, in part: to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed after each use. The manufacturer's instructions listed approved EPA registered wipes for cleaning and disinfecting the glucometer and stated other EPA registered wipes may be used for disinfecting the glucometer used by the facility. The cleaning and disinfecting procedure for Resident #32's individually assigned glucometer included in part: Step 5: using one EPA disinfectant towelette to wipe the entire surface of the glucometer horizontally and vertically to remove bloodborne pathogens and Step 6: Treated surface must remain wet for the recommended contact time. Do not wrap the meter in a towelette. The instructions for the EPA approved disinfectant wipes dated 2023 stated the minute wipe was an effective virucide, bactericide, tuberculocide and fungicide on hard non-porous surfaces. When using the disinfectant wipe, apply the wipe to a hard, non-porous surface (the glucometer), allowing it to remain wet for one minute and allow the surface to air dry. On 2/18/2025 at 7:51 am, Medication Aide #1 (agency) was observed performing blood glucose monitoring using an individually assigned glucometer for Resident #32. After obtaining a blood glucose level, Medication Aide #1 was observed cleaning Resident #32's individually assigned glucometer with alcohol wipes. On 2/18/2025 at 7:57am in an interview with Medication Aide #1, she explained Resident #32's glucometer needed to be disinfected after use and she cleaned the glucometer with an alcohol pad because she did not have any disinfected wipes on the 300-hall medication cart. On 2/18/2025 at 10:25 am in a follow up interview with Medication Aide #1, she stated she received training less than a month ago at the facility on using disinfectant wipes to clean glucometers after use. She stated there were disinfectant wipes on the 300-hall medication cart, and she did not know the disinfectant wipes were on the 300-hall medication cart because she had not checked the 300-hall medication cart. On 2/18/2025 at 11:50 am when interviewing Medication Aide #1 regarding her training in cleaning and disinfecting glucometers after resident use, she reported she had been informed on 2/18/2025 medication aides were not allowed to perform blood glucose monitoring at the facility and stated she would get a nurse to perform blood glucose monitoring. She explained she was in nursing school and had received training in performing blood glucose monitoring and had attended an educational in-service at the facility. On 2/18/2025 at 12:22 pm in an interview with the Administrator, she stated medication aides could perform blood glucose monitoring if training and competency were documented. She explained Medication Aide #1 had received training from the agency company and was currently in nursing school where she received training. On 2/18/2025 at 12:30 pm in an interview with the Director of Nursing, she stated in the last five weeks of employment she had not seen an orientation/competency form that agency staff completed for the facility. On 2/18/2025 at 5:10 pm in follow up interview with the Director of Nursing, she stated Resident #32's individually assigned glucometer needed to be disinfected after each use using a disinfectant wipe and medications aides did not perform blood glucose monitoring at the facility. She stated blood glucose monitoring was completed by licensed nurses in the facility and not medication aides. A skills competency rating dated 9/30/2024 from the agency company indicated Medication Aide #1 performed glucose monitoring daily to weekly and was proficient in the task. An educational in-service roster dated 9/11/2024 and 9/12/2024 on cleaning glucometers between patients every time for infection control practices stated to allow the glucometer to air dry 2 minutes after wiping with purple wipes and place on a clean surface to dry. Medication Aide #1 signature was included on the roster to indicate she had received the education.

Based on record review, observation and staff interview, the facility failed to implement infection control policies and procedures when staff failed to: (1) disinfect an unlabeled glucometer (a blood glucose meter) that was shared between residents for 1 of 2 residents (Resident #35) observed to have a blood glucose level checked. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer's instructions for the glucometer potentially exposes residents to the spread of bloodborne infections. This occurred with six residents in the facility identified as having a diagnosis that included one or more bloodborne pathogens; (2) disinfect an individually assigned glucometer stored outside of the resident's room with an EPA-registered disinfectant in accordance with the manufacturer's instructions of the glucometer (Resident #32); (3) don necessary personal protective equipment (PPE) before entering a COVID isolation room and remove PPE before exiting the room; (4) evidence and documentation of annual review of infection control policies and procedures; and (5) cover the linen on linen carts located in the hallway to reduce the risk of accidental contamination.The uncovered linen carts were observed on 2 of 5 halls (300 and 400 halls). These deficient practices affected 3 of 127 residents residing in the facility (Residents #35, #32 and #230). Immediate jeopardy began on 2/17/2025 at 5:50 am when Nurse #1 was observed performing a blood glucose test on Resident #35 using shared glucometer and not disinfecting the glucometer before and after performing the blood glucose test. Immediate jeopardy was removed on 2/19/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not immediate jeopardy) for findings #2, #3, #4, and #5 for the facility's completion of employee and agency nursing staff training with blood glucose monitoring to ensure effective interventions were implemented. The findings included: 1. The glucometer manufacturer's operator manual dated 2016 provided instructions for cleaning and disinfecting the glucometer used at the facility. It stated, in part: all parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. The meter should be disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. The manufacturer's instructions listed approved EPA registered wipes for cleaning and disinfecting the glucometer and stated other EPA registered wipes may be used for disinfecting the glucometer used by the facility. The cleaning and disinfecting step-by-step instructions included, in part: Step 3: inspect for blood, debris, dust or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4: Clean the meter using a moist lint-free cloth dampened with a mild detergent and wiping all external areas of the meter including the front and back surfaces until visibly clean. Step 5: Disinfect the meter, cleaning the surface with an approved disinfectant wipe and wiping all external areas of the meter including front and back surface until visibly wet. The instructions for the EPA approved disinfectant wipes dated 2023 stated the minute wipe was an effective virucide, bactericide, tuberculocide and fungicide on hard non-porous surfaces. When using the disinfectant wipe, apply the wipe to a hard, non-porous surface (the glucometer), allowing it to remain wet for one minute and allow the surface to air dry. On 2/17/2025 at 5:50 am in preparation to check Resident #35's blood glucose, Nurse #1 was observed searching for Resident #35's glucometer. Nurse #1 stated each resident had their individually assigned glucometer to check blood glucose levels. Nurse #1 was observed opening the top drawer of the 100-hall medication cart flipping three glucometer pouches labeled with Resident #66's, Resident #33's and Resident # 93's name and room number upward toward Nurse #1. Nurse #1 was observed locking the 100-hall medication cart and walking to the 200-hall medication cart before returning to the 100-hall medication cart and reopening the top drawer. Nurse #1 reflipped Resident #66's, Resident #33's and Resident # 93's labeled glucometer pouches upward toward her and picked up Resident #33's glucometer pouch. There was an unlabeled glucometer not in a labeled glucometer pouch observed underneath Resident #33's glucometer pouch. Nurse #1 stated the unlabeled glucometer was Resident #35's glucometer and was observed not disinfecting the glucometer before performing a blood glucose test on Resident #35 on 2/17/2025 at 5:56 am. Nurse #1 was observed returning the used unlabeled glucometer to the top drawer of the 100-hall medication cart without disinfecting the glucometer. On 2/17/2025 at 6:00 am in an interview with Nurse #1, she stated Resident #35 did not have a labeled glucometer pouch and there were two glucometers in Resident #66's pouch earlier, and the glucometer that was not found in a glucometer pouch, must have fallen out of the unzipped glucometer pouch of Resident #66. The glucometer in Resident #66's pouch was observed unlabeled. Nurse #1 stated she did not know which glucometer was Resident #35's and grabbed the unlabeled glucometer that was not in a labeled glucometer pouch to perform Resident #35's blood glucose. Nurse #1 stated the reason she did not disinfect the glucometer before performing the blood glucose was because the staff member who used the glucometer before she used it should have disinfected the glucometer. Nurse #1 stated she did not think about disinfecting the glucometer after performing the blood glucose test. Nurse #1 was observed removing an alcohol pad from the top drawer of the 100-hall medication cart and wiping the unlabeled glucometer without an resident identified glucometer pouch with the alcohol pad and returning the unlabeled glucometer to the top drawer of the 100-hall medication cart. She stated she always disinfected glucometers with alcohol pads and Resident #35 was the only blood glucose monitoring she had to perform. On 2/18/2025 at 10:08 am in an interview with Nurse #2 she stated due to Medication Aide #5 being assigned to the 100-hall medication cart on 2/16/2025 for the 7:00 am to 7:00 pm shift, she performed Resident #35's blood glucose monitoring. She stated Resident #35 did not have an individually assigned glucometer and when performing Resident #35's blood glucose monitoring, the unlabeled glucometer that was not stored in a labeled pouch with resident's name and room number on the 100-hall medication cart was used for Resident #35 and Resident #31, who also did not have an individually assigned glucometer. She stated she used disinfectant wipes on the 100-hall medication cart to disinfect the unlabeled glucometer after each use. On 2/18/2025 at 10:42 am in a follow up phone interview with Nurse #1, she stated she thought the unlabeled glucometer that was not in a pouch labeled with a resident's name and room number on the 100-hall medication cart was Resident #35's glucometer on 2/17/2025 when performing the blood glucose monitoring. She stated Resident #31 also received blood glucose monitoring and did not have an individually assigned glucometer, and she had forgotten Resident #35 and Resident #31 shared the unlabeled glucometer not in a labeled pouch. Nurse #1 stated she was trained on how to use and disinfect a glucometer with employment orientation and was unable to recall the instructions on how to use the disinfectant wipes at the facility. She reported there were no disinfectant wipes on the 100-hall medication cart to clean the glucometer on the morning of 2/17/2025. On 2/18/2025 at 10:30 am in an interview with the Central Supply, she reported there were no disinfectant wipes in the central supply room. She stated she restocked the 100-hall medication cart with disinfectant wipes on the morning of 2/17/2025 upon reporting to work for the 7:00am to 3:00pm shift. On 2/17/2025 at 6:50 am in an interview with the Director of Nursing (DON), she stated the facility did not have an individually assigned glucometer for every resident receiving blood glucose monitoring, and there were glucometers on the medication carts that were shared between residents. The DON stated Nurse #1 should have disinfected the glucometer that was shared between the residents with the facility's EPA-disinfectant wipes and allow the glucometer to dry for two minutes before storing in resident's labeled glucometer pouch. The Regional Director of Clinical Services indicated via email on 2/18/2025 at 5:26 pm that there were six current residents in the facility identified as having a diagnosis that included one or more bloodborne pathogens. The Administrator was informed of the immediate jeopardy (IJ) on 2/18/2025 at 2:00 pm. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Nurse #1 failed to ensure an unlabeled / unidentified glucometer that was shared between Resident #35 and Resident #31 on the 100-hall medication cart was cleaned and disinfected prior to and after use. (Resident #35). Nurse #1 thought the glucometer was individually assigned to Resident #35 and had forgotten that the unlabeled / unidentified glucometer was also used on Resident #31. Nurse #1 indicated the glucometer used for Resident #35 was individually assigned. She stated she did not think about cleaning and disinfecting the unlabeled / unidentified glucometer after performing Resident #35's blood glucose and stated she always cleaned residents' glucometer with alcohol wipes. The Director of Nursing stated the facility did not have a glucometer for every resident receiving blood glucose monitoring and some of the glucometers on the medication carts were shared between residents. The DON stated glucometers were to be cleansed with an approved disinfectant. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an EPA-registered disinfectant in accordance with the manufacturer's instructions to disinfect a shared glucometer potentially exposes residents to the spread of blood borne infections. There are six current residents within the facility identified as having a diagnosis which included one or more blood borne pathogens. The following immediate actions were taken for affected residents: The facility Medical Director was notified by the Administrator of the facility on 2/18/2025 of the deficient practice for Resident #35 and of the new process of each resident having their own designated glucometer. He is in agreement with the current process for cleaning and storage of glucometers with no further recommendation. No recommendations were provided for Resident #35. The local county Health Department Communicable Disease Coordinator was notified by the facility Administrator on 2/18/2025 with no further recommendations at this time. Current residents that receive finger stick blood sugar checks are at risk. Forty residents require FSBS and all forty have been provided their individual glucometer. The Assistant Director of Nursing completed an audit on 2/18/2025. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Current residents who require finger stick blood sugars received their own individual glucometers and they were labeled and placed in an individual container. The was completed by the Director of Nursing and the Assistant Director of Nursing on 2/18/2025. Education was started by the Director of Nursing on 2/18/2025 to current licensed nursing staff, including agency staff, on proper procedure for cleaning/disinfecting glucometers and for proper storage of glucometers. Employees not receiving this education will not be allowed to work until the education is received. The Director of Nursing will track the education to ensure that current staff have received. Education includes each resident who receives a finger stick blood sugar will have an individual glucometer that is labeled with their name and stored in an individual container inside the med cart. Education also includes the proper cleaning technique as recommended by the manufacturer guidelines. The cleaning product will be kept on each medication cart. The Director of Nursing or charge nurse will check the med carts daily to ensure that the cleaning product is present on each med cart. The Director of Nursing educated the charge nurses on 2/18/2025. The Director of Nursing was educated on this process by the Administrator on 2/18/2025. The Director of Nursing or charge nurse is responsible for ensuring new admissions who require finger stick blood sugars are provided with their own individual glucometer that is labeled with their name and stored in an individual container. The Director of Nursing was educated on this process by the Administrator on 2/18/2025. The charge nurses are educated on this process by the Director of Nursing on 02/18/2025. New licensed nurses will receive this education during the orientation process by the Director of Nursing or charge nurse on 02/18/2025. Agency nurses will receive this education prior to the start of their shift. The charge nurses were educated on this process on 02/18/2025 by the Director of Nurse. The Director of Nursing will assign the charge nurse to complete this task when needed. Immediate Jeopardy Removal Date: 2/19/2025 The facility's credible allegation of immediate jeopardy removal was validated on 2/22/25. A phone interview with the medical director on 2/18/2025 validated the facility had notified the physician of the deficient practice and the facility was implementing new practices that included an individual glucometer per resident and educating the nursing staff on how to disinfect the glucometer after use on a resident. Observation of the 43 residents' (40 plus 3 admissions since 2/18/2025) individually assigned glucometers who currently resided in the facility on 2/22/2025 validated each resident receiving blood glucose monitoring had an individually assigned glucometer in a glucometer pouch labeled with their name and room number. Interviews with licensed nursing staff on each hallway and on all shifts validated in-service training was conducted in regard to the use of individually assigned glucometers for resident blood glucose monitoring and the infection control practices for the disinfection of glucometers. All licensed nursing staff who were interviewed reported they had received the required in-service training on 2/18/2025 or prior to beginning their next assigned shift after 2/18/2025. The educational in-services stressed using individually assigned glucometers for each resident requiring blood glucose monitoring and storing each individual assigned glucometer in an individually labeled glucometer pouch with resident's name and room number. The in-service training also included a review of the manufacturer's instructions for the facility's glucometers and disinfectant wipes related to disinfection of the glucometer and completion of a returned demonstration of the proper procedure for effective glucometer disinfection. Nurse observation in conducting a blood glucose check and subsequent glucometer disinfection completed the task without difficulty. Individually assigned resident glucometers were observed stored on the medication carts in closed labeled pouches with resident's name and room number. Each medication cart was observed with a canister of EPA disinfectant wipes. There was an unused unlabeled new glucometer observed on each medication cart that licensed nursing staff validated through interviews the new unused glucometers were available for new admissions, replacement of a resident's individually assigned glucometer or in an emergency as needed. To prevent the likelihood of a new glucometer used as a shared glucometer, the facility removed the new, unused glucometers from each medication cart and relocated the storage of the new unused glucometer into the medication storage rooms on each unit. There were no further concerns identified during either the interviews or observations. The immediate jeopardy removal date of 2/19/2025 was validated. 2. The manufacturer's operator manual revised 10/2019 for Resident #32's assigned glucometer provided instructions for cleaning and disinfecting the glucometer used at the facility. It stated, in part: to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed after each use. The manufacturer's instructions listed approved EPA registered wipes for cleaning and disinfecting the glucometer and stated other EPA registered wipes may be used for disinfecting the glucometer used by the facility. The cleaning and disinfecting procedure for Resident #32's individually assigned glucometer included in part: Step 5: using one EPA disinfectant towelette to wipe the entire surface of the glucometer horizontally and vertically to remove bloodborne pathogens and Step 6: Treated surface must remain wet for the recommended contact time. Do not wrap the meter in a towelette. The instructions for the EPA approved disinfectant wipes dated 2023 stated the minute wipe was an effective virucide, bactericide, tuberculocide and fungicide on hard non-porous surfaces. When using the disinfectant wipe, apply the wipe to a hard, non-porous surface (the glucometer), allowing it to remain wet for one minute and allow the surface to air dry. On 2/18/2025 at 7:51 am, Medication Aide #1 (agency) was observed performing blood glucose monitoring using an individually assigned glucometer for Resident #32. After obtaining a blood glucose level, Medication Aide #1 was observed cleaning Resident #32's individually assigned glucometer with alcohol wipes. On 2/18/2025 at 7:57am in an interview with Medication Aide #1, she explained Resident #32's glucometer needed to be disinfected after use and she cleaned the glucometer with an alcohol pad because she did not have any disinfectant wipes on the 300-hall medication cart. On 2/18/2025 at 10:25 am in a follow up interview with Medication Aide #1, she stated she received training less than a month ago at the facility on using disinfectant wipes to clean glucometers after use. She stated there were disinfectant wipes on the 300-hall medication cart, and she did not know the disinfectant wipes were on the 300-hall medication cart because she had not checked the 300-hall medication cart. On 2/18/2025 at 5:10 pm in an interview with the Director of Nursing, she stated Resident #32's individually assigned glucometer needed to be disinfected after each use using a disinfectant wipe. 3. The facility's policy for COVID-19 dated 10/24/2024 stated in part: to implement Special Droplet-Contract Precautions until patient meets the Center of Disease Control and Prevention criteria for discontinuation of transmission -based precautions. The facility's policy Transmission Based Precautions-General Practice dated 12/1/2021 stated in part: to maintain transmission based precautions before entering the patient's room and fundamental protective measures: hand washing, use of mask, eye protection, gowns and gloves. Supplies are kept near the entrance and large trash can for general trash placed inside the room. When donning the protective attire: wash hands, put on gown, apply mask, put on goggles or face shield if required. Removing of protective attire in the patient's room in the trach can: gloves, goggles or face shield, gown and mask. On 2/17/2025 at 4:20 am, Nurse #5 was observed applying an isolation gown, gloves and N-95 mask before entering Resident #230' room. On 2/17/2025 at 4:22 am, there was a droplet precautions sign observed posted on Resident #230's door. A three-drawer container was observed outside Resident #230's door and contained gowns, face mask, N-95 mask, gloves and eye protection. Nurse #5 was observed inside Resident #230's room preparing to obtain Resident #230 vital signs not wearing eye protection. On 2/17/2025 at 4:27 am, Nurse #5 was observed exiting Resident #230's room into the hallway and removing the isolation gown, gloves and N-95 and discarding the personal protective equipment (PPE) into one of two large trash cans observed located in the hallway outside of Resident #230's room. On 2/17/2025 at 4:29 am in an interview with Nurse #5, she stated Resident #230 was on isolation for COVID-19 that required contact and droplet precautions. She stated she did not place the droplet precautions signage on Resident #230's door. She stated eye protection was available to wear and stated she did not need to wear eye protection to enter Resident #230's room because she was fully vaccinated against COVID-19. She explained she removed the PPE (gown, gloves and N-95 mask) after exiting Resident #230's room because of the large grey trash cans were located outside Resident #230's room and she didn't want to contaminate herself inside the room. Nurse #5 stated she was an agency nurse and had received infection control training from the agency. She stated she had worked at the facility for one week and had not received COVID-19 and PPE training from the facility. On 2/18/2025 at 5:28 pm in an interview with Unit Manager #1, she stated she had made an error and placed the wrong isolation signage for droplet precautions on Resident #230's door. She stated the droplet precautions signage did not include the use of a N-95 mask, gown or eye protection to enter Resident #230 room and the posted signage on Resident #230's door should have been special droplet and contact precautions. She stated the required PPE (gown, gloves, N-95 mask and face shield for eye protection) were placed outside Resident #230's door for the staff to use and the trash cans should have been inside Resident #230's room for Nurse #5 to remove the PPE inside Resident #230's room before exiting the room. On 2/18/2025 at 5:10 pm in an interview with the Director of Nursing (DON), she stated Resident #230 was admitted with COVID-19 and she did not know exactly which isolation signage was to be posted on Resident #230's door. She explained Unit Manager #1 was responsible for posting the isolation precaution signage on Resident #230 door. The DON stated Nurse #5 should have worn eye protection before entering Resident #230's room to provide resident care and should have removed the PPE before exiting Resident #230's room. The DON reported that when she started five weeks ago at the facility she was informed that infection control was her responsibility also, and she had not performed any tasks (training, reports) related to infection control. 4. Review of the facility's Infection Prevention and Control Policies and Procedures revealed an Infection Prevention and Control Manual with an effective date of 2/6/20 with no evidence of annual review. During an interview with the Director of Nursing (DON) #1 on 2/17/25 at 5:06 pm, she stated she was responsible for the Infection Prevention and Control program. The DON #1 further stated she had been in the DON position for 5 weeks and had been unable to review the Infection Prevention and Control Policies. In an interview with Corporate Nurse Consultant #1 on 2/22/25 at 5:00 pm, she stated the facility was currently working on their Infection Prevention and Control program. The Corporate Nurse Consultant #1 did not have documentation of annual review and signed Infection Prevention and Control policies and procedures. 5. Review of the facility's Infection Prevention and Control policy and procedures for linen read, Clean towels will be kept covered and available for individual use. The clean linen cart on the 300 hall was observed on 2/17/25 at 3:28 pm with the front cover pulled up and resting on the top of the mesh covered plastic pipe line cart. During an interview with Unit Manager #1 on 2/17/25 at 3:30 pm, she stated all linen carts should be covered for infection control purposes. Unit Manager #1 placed the covering correctly on the linen cart. A continuous observation was made on 2/18/25 from 9:03 am until 9:10 am of the linen cart on the 400 hall. The front cover was pulled up and was resting on the top of the mesh covered plastic pipe linen cart. Clean gowns, towels, wash clothes, and blankets were observed on the cart. The maintenance staff was observed walking by pulling furniture at 9:05 am and Physical Therapy staff was observed walking by at 9:06 am. A NA was observed walking by with bagged trash in hand at 9:09 am. Another NA with a plate and cup in hand was observed walking by at 9:09 am. The linen cart front covered was closed by a NA at 9:10 am. During an interview on 2/28/25 at 9:35 am with NA #5, she stated the linen carts should be covered after retrieving the items needed for resident care for infection control prevention. The clean linen cart on the 300 hall was observed for a second time on 2/21/25 at 12:29 pm with the front covering on top of the linen cart. During an interview with Nursing Assistant (NA) #3 on 2/21/25 at 12:39 pm, she stated the linen carts are supposed to be covered when not in use due to infection control prevention. She immediately placed the covering on the linen cart correctly. During an interview with the Housekeeping Manager on 2/18/25 at 3:00 pm, she indicated the linen carts on the hall ways held clean gowns, towels, wash clothes, and blankets for the residents. She further indicated the linen carts should be covered when not in use by the staff. In an interview with the Administrator and Corporate Nurse Consultant #1 on 2/22/25 at 5:00 pm, the Administrator stated she expected the linen carts to be covered when the nursing staff were not using them. The Corporate Nurse Consultant #1 indicated they were working on the infection control program at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, family, and physician interview, the facility to provide accurate notification to the physician of repeated episodes of Resident 22's blood glucose level registering greater than 400 milligrams per deciliter (mg/dL) (normal blood glucose level are considered to be between 70 mg/dL to 100 mg/dL) over two days and to notify the resident's physician and family when Resident #22 was found to be nonresponsive by a physical therapy staff member hours before Emergency Medical Services (EMS) was called. Resident #22 was found with an elevated heart rate of 140 beats per minute (bpm) (a typical resting heart rate for adults is between 60 and 100 bpm), respirations in the 40s breaths per minute (a normal respiratory rate is between 12 and 20 breaths per minute), and with a continued reading of a blood glucose level more than 400 mg/dL at time of transport by EMS. At the time of ED (emergency department) physician assessment, Resident # 22 was diagnosed with sepsis (a life-threatening complication of an infection) and hyperglycemia. (Hyperglycemia is the technical term for high blood glucose levels that occurs due to the body having too little insulin or when the body can't use insulin properly.) This was for one (Resident #22) of three residents reviewed for notification of physician for a change in medical condition. Immediate jeopardy began on 7/10/2024 when Resident #22 was identified as having a blood glucose reading of over 400 mg/dL and the physician was not notified. Immediate Jeopardy was removed on 9/9/2024 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Findings included: Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses which included type 2 diabetes mellitus. Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive Novolog insulin solution to be injected subcutaneously (under the skin) three times day at 8:00 AM, 12:00 PM, and 4:00 PM per the following sliding scale: If the blood glucose level was 201 mg/dL to 250 mg/dL administer 4 units; 251 mg/dL to 300 mg/dL administer 6 units; 301 mg/dL to 350 mg/dL administer 8 units; 351 mg/dL to 400 mg/dL administer 10 units; greater than 400 mg/dL call the physician. Novolog is a fast-acting insulin used to treat high blood glucose for people with diabetes. There was no documentation on the July (Medication Administration Record) (MAR) Resident #22 had a blood glucose level taken or received Novolog insulin as ordered at 8:00 AM on 7/10/2024. Documentation on the July MAR revealed Medication Aide (Med Aide) #4 took a blood glucose level of 400 mg/dL and administered 10 units of Novolog insulin on 7/10/2024 at 1:43 PM to Resident #22. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or was administered Novolog insulin as ordered at 4:00 PM on 7/10/2024. There was no documentation in the electronic medical record of Resident #22 that any additional interventions were taken for the elevated blood glucose reading on 7/10/2024 at 1:43 PM. Med Aide #4, an agency employee, was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 revealed the following information. On the morning of 7/10/24 Med Aide #4 was assigned for the 7:00 AM to 7:00 PM shift to the hallway which Resident #22 resided. Nurse #4 relayed to Med Aide #4 that she had already administered the morning medications to include insulin administration for Resident #22 on the 7:00 PM to 7:00 AM shift that ended on 7/10/2024. Med Aide #4 indicated she did not know what the blood glucose level of Resident #22 was at 8:00 AM. Med Aide #4 explained that she could not remember which licensed nurse was assisting her on 7/10/2024 at the 12:00 PM administration time but she thought it was Unit Manager #2. Med Aide #4 confirmed she did not administer Novolog insulin to Resident #22 on 7/10/2024 at 1:43 PM, because she was not allowed to administer insulin to residents under her scope of practice as a medication aide. According to Med Aide #4 on 7/10/2024 the blood glucose level for Resident #22 read as HI or above 400 mg/dL on the glucose monitor and Unit Manager #2 was made aware. (A reading of HI on a glucometer means the reading is above the level readable by the glucometer.) She revealed the MAR did not allow Novolog insulin to be checked off as administered unless an actual number was entered into the MAR for the blood glucose reading. Med Aide #4 stated she had to put in 400 mg/dL although the reading may have been over 400 mg/dL. Med Aide #4 indicated she was told by Unit Manager #2 the physician for Resident #22 was called and had ordered 12 units of Novolog insulin to be administered to Resident #22 and to keep checking the blood glucose level every hour. Med Aide #4 kept checking the blood glucose level every hour and reported to Unit Manager #2 the glucose reading was still registering as above 400 mg/dL. Med Aide #4 thought Unit Manager #2 was going to document everything and take care of the 4:00 PM scheduled Novolog insulin administration on 7/10/2024 because of the blood glucose readings that were over 400 mg/dL, requiring a physician to be notified. Unit Manager #2 was interviewed on 9/10/2024 at 8:21 AM. Unit Manager #2 revealed the following information. Unit Manager #2 did recall Med Aide #4 contacting her about an elevated glucose level for Resident #22 on 7/10/2024. Unit Manager #2 revealed she assessed Resident #22 and thought she was dehydrated but was arousable and able to drink fluids. Unit Manager #2 revealed she thought she sent a text to the physician for Resident #22 informing him of the elevated blood glucose levels on 7/10/2024 but, she could not recall specifically if she had done so. There was no documentation on the July MAR Resident #22 had a blood glucose reading taken or was administered Novolog insulin as ordered at 8:00 AM on 7/11/2024. The facility nursing schedule dated 7/11/2024 indicated Nurse #7 was assigned to the hallway for which Resident #22 resided for the 12 hour day shift (7:00 AM to 7:00 PM). Nurse #7 was interviewed on 9/5/2024 at 2:37 PM. Nurse #7 stated she was an agency nurse who only worked at the facility on one occasion and that was 7/11/2024 for the 7:00 AM to 7:00 PM shift. Nurse #7 revealed when she arrived at the facility, she was not given login information for the electronic medical record system and was given paper MARs to work with for documentation of administration of the medications for residents on the hallway she was assigned. Nurse #7 revealed she was unable to recall what residents she took blood glucose levels for, but she would have documented calling the physician for an elevated blood glucose if that had been required of her. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 11:47AM to Resident #22. Documentation on a physical therapy treatment encounter note for Resident #22 written by Physical Therapy Assistant (PTA) #1 on 7/11/2024 at 3:58 PM revealed, PTA facilitated that [Resident #22] get [out of bed] for the purpose of attempting goals. [Resident #22] responded [by demonstrating] extreme lethargy, incoherent mumbling, [nonresponsive] pupils/eye movement to bright light. PTA attempted to have [Resident #22] sit [on edge of bed] with [Resident #22 [demonstrating] inability to arise from sleep/difficulty to hold head. Nursing [Med Aide #4], DON (Director of Nursing), [Physical Therapist/Occupational Therapist] notified regarding [Resident #22's] decrease in status. Continue [with plan of care.] An interview was conducted with PTA #1 on 9/6/2024 at 4:45 PM. PTA #1 revealed the following information. PTA #1 stated she did not recall the exact time she went to see Resident #22 on 7/11/2024. PTA #1 confirmed she found Resident #22 in a nonresponsive condition on that day, so she went to the Med Aide on the hall, the interim DON, the Physical Therapist, and Occupational therapist to let them know of her concern for Resident #22. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 4:51 PM. Med Aide #4 was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 revealed the following information. Med Aide #4 confirmed she took the blood sugar readings for Resident #22 on 7/11/2024 at 11:47 AM and 4:51 PM. Med Aide #4 revealed that some of the blood glucose readings for Resident #22 were registering as HI or over 400 mg/dL while at least one of the readings she documented on the MAR on 7/11/2024 was actually 400 mg/dL. Med Aide #4 confirmed she told the licensed nurse who was assisting her on 7/11/2024 for the 12:00 PM and 4:00 PM administration time for the Novolog insulin, that the blood glucose levels were continuously registering as HI. Med Aide #4 was told by the licensed nurse on 7/11/2024 the physician had been contacted and ordered for Resident #22 to be monitored. Med Aide #4 did not recall who the licensed nurse was. Med Aide #4 confirmed PTA #1 informed her of concerns of the lack of response from Resident #22. Med Aide #4 stated she did tell the licensed nurse of what PTA #1 had said. Med Aide #4 stated she informed Unit Manager #2 and sent a text message to the interim DON about the continued blood glucose readings of over 400 mg/dL for Resident #22. Med Aide #4 stated she got a text message back from the interim DON that she would take care of it. Med Aide #4 stated that in report at the end of her shift on 7/10/24 and 7/11/24 she let Nurse #4 know Resident #22 was continually having blood glucose readings of over 400 mg/dL. Med Aide #4 indicated Nurse #4 did not seem to care, telling her that on the shift, 7:00 PM to 7:00 AM, when Nurse #4 worked, the blood glucose readings for Resident #22 were in the 200's mg/dL. Med Aide #4 stated, It just didn't make any sense to me but only the nurses can call the doctor. Documentation in the physician orders revealed an order dated 7/11/2024 at 7:00 PM for Resident #22 to be administered ten units of Humalog insulin solution to be injected subcutaneously one time only for a blood glucose exceeding 400 mg/dL and contact the physician in two hours. Humalog insulin is a fast-acting insulin which is absorbed quickly and starts working in about 15 minutes after injection to lower blood glucose levels. There was no documentation on the July MAR that the order for Humalog insulin was administered to Resident #22 on 7/11/2024 after 7:00 PM. Documentation in the physician orders revealed an order dated 7/11/2024 at 9:00 PM for Resident #22 to be administered ten units of Novolog insulin solution subcutaneously one time for blood glucose exceeding 400 mg/dL and contact the physician in two hours. There was no documentation on the July MAR that the one-time order for Novolog insulin was ever administered to Resident #22 on 7/11/2024 after 7:00 PM. Documentation in the nursing notes for Resident #22 dated 7/12/2024 at 9:48 AM by Nurse #4 revealed, Physician contacted due to blood glucose exceeding 400 (mg/dL) and order received from physician to administer 10 [units] of Humalog or Novolog and report back after 2 hours. After 2 hours, resident blood [glucose] reading still exceeded 400 (mg/dL) and physician made aware of results. Family arrived and RP (Responsible Party) requested for resident to be sent to [emergency room] for evaluation. Physician made aware and order received to send resident to [emergency room]. DON made aware. An interview was conducted with Nurse #4 on 9/5/2024 at 6:04 PM. Nurse #4 relayed the following information and timeline of events for Resident #22 on the evening of 7/11/2024. Nurse #4 started her 7:00 PM to 7:00 AM shift at 7:00 PM on 7/11/2024. Nurse #4 received the information in a nursing report from Med Aide #4 that the blood glucose level of Resident #22 was above 400 mg/dL on the 4:00 PM medication pass. Nurse #4 denied she had any knowledge of the blood glucose level of Resident #22 being at or above 400 for several shifts. Nurse #4 stated she assessed Resident #22 and took her vital signs at the start of her shift. Nurse #4 revealed the blood glucose level of Resident #22 was registering as High or over 400 on the glucometer, a device to measure blood glucose levels. Nurse #4 revealed the vital signs of Resident #22 were fine, so she called the on-call physician. Nurse #4 stated she received an order from the physician to administer 10 units of fast acting insulin to Resident #22 and call the physician back in two hours. Nurse #4 stated she went back to check on Resident #22 again at 9:00 PM and all her vital signs were fine. Resident #22 did not have a temperature, elevated blood pressure, or an elevated heart rate. Nurse #4 stated her blood glucose level was still registering as High or above 400 mg/dL on the glucometer. Nurse #4 was adamant Resident #22 was fine and was responsive. Nurse #4 related that when she pricked the finger of Resident #22 with the lancet, the resident looked at her and rolled her eyes. Nurse #4 stated the family of Resident #22 arrived at the facility stating they received a phone call from an unknown caller telling them something was wrong with Resident #22, and she needed to be sent to the emergency room. The family of Resident #22 looked at Resident #22 and demanded she be sent to the emergency room. Nurse #4 stated she did not know who called the family because the breathing and vital signs for Resident #22 were normal. Nurse #4 reported she was about ready to call the physician because of the elevated blood glucose reading, so she called the physician, and the physician agreed Resident #22 could be sent out per the family wishes. An interview was conducted with the responsible party (RP) for Resident #22 on 9/3/2024 at 3:42 PM and the following information was provided. On 7/8/2024 the RP checked on Resident #22 before going out of town and she was okay. The RP heard nothing all week from the facility. On 7/11/24 around 7:30 PM to 8:00 PM she saw she had several missed calls on her phone. She then picked up on the next one. It was from a private number. The person on the phone did not identify themselves but told the RP, You need to come now and check on your mother. It is an emergency. She needs to be sent out. The RP did not know what was going on because the facility did not notify her that Resident #22 was sick. The RP called another family member who was local to the facility and asked him to go to the facility to see Resident #22. The family member arrived at the facility around 8:30 to 8:45 PM to find Resident #22 was not responding. Nurse #4 walked into the room with a blood glucose monitor and said the doctor ordered Resident #22 to receive 10 units of insulin, to monitor her blood glucose level, and call the doctor back in two hours. Since Resident #22 was not responding the family member insisted that Resident #22 be sent to the emergency room and finally Nurse #4 called emergency medical services (EMS). The RP talked to the (former) Administrator about her concerns and the (former) Administrator informed the RP that the facility had learned that a physical therapy staff member had noted a change in the resident earlier that day (7/11/2024). The (former) Administrator maintained that they did not have to let the family know if Resident #22 had elevated blood glucose levels, which did not make sense to her. If she had known that Resident #22's blood glucose levels were running high for several days she would have wanted her sent to the hospital to be checked. An interview was conducted with the interim DON on 9/5/2024 at 1:58 PM. The interim DON stated she was not made aware of any concerns with the blood glucose levels of Resident #22 until the RP called her on the evening of 7/11/2024 at approximately 8:00 PM or 8:30 PM. The interim DON was told by the RP of a phone call she received from a facility staff member telling her Resident #22 was very ill and needed to be sent to the hospital. The interim DON relayed she called Nurse #4 and was told Resident #22 was still at the facility and was fine. The interim DON further revealed Nurse #4 had explained the following interventions for Resident #22. An assessment had been completed by Nurse #4 revealing an elevated blood glucose level, lethargy, vital signs were fine, the physician was called for orders, and Resident #22 was responsive. The interim DON stated she knew the blood glucose level of Resident #22 was high in the moment on the evening of 7/11/2024 but she was not aware the blood glucose level had been high over several shifts. Documentation on an Emergency Medical Services (EMS) report dated 7/11/2024 revealed 911 was called at 9:17 PM and arrived at room of Resident #22 at 9:37 PM. The following information was revealed in the EMS report. Upon arriving at the scene, the facility staff stated Resident #22 had been having an elevated blood glucose level all day and had been alert but not acting like herself. The facility staff also told EMS they had been giving Resident #22 insulin as instructed by the resident's physician with no changes in the reading level of HI on the glucose monitor. EMS noted Resident #22 had a glucose reading of High on their glucose monitor as well. EMS documented Resident #22 as having a heart rate of 140 with respirations in the 40s. Once in the ambulance, Resident #22 remained unresponsive. Documentation on a hospital record dated for a 7/11/2024 admission revealed Resident #22 was diagnosed with sepsis, hyperglycemia, altered mental status, acute renal failure, dehydration, and a urinary tract infection in the emergency room. An interview was conducted with Medical Doctor (MD) #2, the physician for Resident #22, on 9/9/2024 at 1:12 PM. MD #22 stated he could not recall if he was notified of the elevated blood glucose levels of Resident #22 on 7/9/2024, 7/10/2024, or 7/11/2024. MD #2 explained that if he had been notified of elevated blood glucose levels for Resident #22 during normal business hours, he would have ordered a change in the amount of fast-acting insulin to be administered and requested a call back if there was no change after continuous monitoring of the resident. MD #2 indicated that if those orders did not exist on 7/10/2024 or 7/11/2024 during the day shift then it was likely he was not notified. MD #2 stated he did not recall receiving a phone call on the evening of 7/11/2024 from Nurse #4, but he received phone calls of that type routinely making it difficult to recall a specific phone call of that type for a resident. MD #2 stated that a blood glucose level of 400 mg/dL was not good, but having a blood glucose level of 400 mg/dL was an isolated event for this resident making it likely an underlying medical condition was occurring for which he would have had to figure out. On 9/9/24 at 5:04 PM the facility Administrator and Corporate Nurse Consultant were notified of Immediate Jeopardy. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #22 was admitted to the facility on [DATE] and discharged on 07/11/2024. Between the original admission and discharge, she was readmitted on [DATE]. The most recent readmission, she was readmitted with diagnoses that included: Type 2 diabetes with diabetic retinopathy without macular edema (a complication of diabetes that can cause vision loss and blindness), schizoaffective disorder, dementia, chronic embolism (long-term condition where one or more blood clots block the pulmonary arteries), and thrombosis of distal lower extremity (a blood clot condition that forms within the deep veins, usually of the leg, but can occur in the arms). Review of Resident #22's Medication Administration Records (MAR), indicates; on 7/10/24 at 1:43pm the medication aide (MA #4) notified Unit Manager #2 that Resident #22 had blood glucose levels registering over 400. No evidence that the physician was notified. Resident #22's MAR indicates that Resident #22 received 10 units of Novolog insulin at 1:43pm. Further review of Resident #22's MAR indicates; on 7/11/2024, at 11:47 am, Resident #22's blood glucose was documented to be 400. No evidence that the physician was notified, and 10 units of fast-acting insulin were administered. Review of the Physical Therapy Assistant documentation on 7/11/24 at 3:38 PM indicated the resident was non-responsive, and the Director of Nursing was notified. No documentation of actions taken. The Director of Nursing who was informed is no longer working at the facility. No evidence that the physician was notified. On 7/11/24 at 4:51pm blood glucose documented by MA #4 to be 400. The MAR indicates Resident #22 received 10 units of Novolog insulin. No evidence that the physician was notified, no indication that anything else was done. Review of progress notes documented on 7/12/2024 (late entry for 7/11/2024), in Resident #22's medical records indicate (in part); Nurse #4 contacted physician due to Resident #22's blood glucose exceeding 400. An order was received from the physician to administer ten units of Humalog or Novolog and report back after 2 hours. After two hours, Resident #22's blood glucose reading still exceeded 400 and the physician made aware of results, the note added. Resident #22's family arrived and requested that Resident #22 to be sent to the hospital for evaluation. The physician made aware, and the order received to send resident to hospital, documentation concluded. A phone interview was conducted on 09/07/2024 by the Assistant Director of Nursing. Nurse #4 indicated; she contacted the physician around 7:10pm on 7/11/2024 due to Resident #22's blood glucose exceeding 400. Nurse #4 added she received an order to administer ten units of Humalog or Novolog and report back after 2 hours. Nurse #4 indicated that she recalled administering 10 units of Novolog to Resident #22 per physician order. Nurse #4 further added that, at approximately 9:00pm, she rechecked Resident #22's blood glucose, the reading still exceeded 400. She added the physician was made aware of the results at approximately 9:03pm. Per Nurse #4, Resident #22's family arrived at approximately 9:05pm and requested for Resident #22 be sent to the hospital. The physician was made aware of the request at approximately 9:10pm, and the order was received to send the resident to hospital, Nurse # 4 contacted EMS at 9:17pm, interview concluded. EMS arrived on scene at 9:32pm. Resident #22 was still non-responsive when EMS arrived. Per EMS report, Resident #22 was found with an elevated heart rate of 140, respirations in the 40s, and with a continued reading of a blood sugar in excess of 400 at time of transport. Resident #22 was sent to the hospital for further evaluation and treatment, Resident #22 left the facility at approximately 9:53pm. Resident #22 is no longer in the facility. No other actions taken. The Governing body led by the [NAME] President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis on 09/06/2024, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. For Resident #22, the Root Cause Analysis (RCA) identified the alleged noncompliance resulted from the failure of the facility employee (Nurse # 4) to follow the professional standard of practice to inform the attending physician of the elevated blood glucose levels that were sustained over a two-day time frame and over multiple shifts for Resident #22. The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring. Clinical assessments of all current residents in the facility were completed on 09/07/24 by the Director of Nursing, Assistant Director of Nursing, and/or Unit coordinator (#1 or #2) to identify any other resident with the change condition that require medical attention and/or notification to the physician. The clinical assessment focused on resident's vital signs to include, blood pressure reading, pulse, respiration rate, temperature, and/or presence of pain. The assessment also includes measuring blood glucose for the residents with diagnosis of diabetes with orders for blood glucose check. The attending physician will be informed by the Director of Nursing, Assistant Director of Nursing and/or Unit Coordinator #1 or #2) on any identified findings of a change in condition and appropriate measures to include, but not limited to activating emergency medical services if indicated. 100% audit of all current resident's blood glucose reading documented from 6/28/2024 to 09/07/2024 completed on 09/07/2024 and 09/08/2024, by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinator (#1 or #2) to identify any other documentation of a resident with episodes of hypoglycemia and/or hyperglycemia to ensure notification to the attending physician was made. Any resident(s) identified with a change in condition, the Director of nursing will inform the physician for appropriate measures and or interventions and implement the interventions as ordered. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Effective 09/07/2024, facility employees will ensure significant changes, to include hypoglycemia and/or hyperglycemia, were reported to the physician for appropriate intervention. This systemic modification will be accomplished by implementing the following measures: Effective 09/09/2024, licensed nurse on duty will inform the resident; consult with the resident's physician; and notify, the resident representative when there is; an accident involving the resident which results in injury and has the potential for requiring physician intervention, a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment), and/or a decision to transfer or discharge the resident from the facility, to including when resident's blood glucose is excessive high or low blood glucose. This notification will be documented on each resident's electronic medical records by the licensed nurse on duty. Effective 09/09/2024, the facilities nursing administrative team, which includes the DON, ADON, Unit coordinators (#1, #2), and/or wound nurse, incorporated the process for reviewing clinical documentation for the last 24 hours and physician orders written in the last 24 hours, or from the last clinical meeting to ensure any needed notification of changes to the physician, and/or responsible party was done in a timely manner. This systemic process will take place Monday through Friday. Any identified issues will be addressed promptly. This process will be incorporated into the daily clinical meeting. The nursing administrative team will review the clinical documentation and physician orders written on Friday and/or Saturday on the next clinical meeting on the following Monday. Effective 09/07/2024, for residents with orders for blood glucose check; certified medication aides will obtain and document blood glucose reading in each resident's medical records, and inform a Nurse on duty immediately, on any blood glucose level less than 60, greater than 200 or based on the physician order. Facility licensed nurses on duty will assess the resident blood glucose level and provide appropriate intervention including notifying the physician in a timely manner. 100% education of all licensed nurses to include full time, part time, and as needed licensed nurses will be completed by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and/or Unit Coordinators (#1, #2). The emphasis of this education will be the importance of notifying physician and the responsible party in a timely manner for any change in condition, change of treatment/intervention, and/or incidents of sustained elevated blood glucose. This education will be completed by 9/09/2024, any licensed nurses not educated by 09/09/24 will not be allowed to work until educated. This education will also be implemented in new hire orientation. Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (#1, #2) will monitor and track the completion of this education and will complete this education for any newly hired licensed nurses during the new hire orientation effective 09/09/2024. Alleged immediate jeopardy removal date: 09/09/2024. On 9/12/24 the following was done to validate the facility's immediate jeopardy removal plan: Review of records revealed documentation confirming the completion of audits and in-service training per the facility's removal plan. A review of staffing schedules revealed that there was a designation on the schedule noting which licensed nurse was assigned to cover for any Medication Aide so that physician notification could take place when needed. Beginning at 9:45 AM on 9/12/24 multiple staff members were interviewed regarding in-service training the facility had provided. Staff were able to report details of their training and validated they attended. Staff were also interviewed regarding whether they had witnessed any resident go without medical care during the past week for failure of assessment and notification of the physician of changes. There were no reports of a lack of medical care for acutely ill residents due to a lack of physician notification. A random interview was conducted on 9/12/24 at 1:35 PM with an alert and oriented diabetic resident regarding her medical care. The resident reported no problems with her diabetic care due to staff not communicating with the physician. The facility's immediate jeopardy removal, date of 9/9/24, was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, family interview, and physician interview the facility failed to protect a resident's right to be free from neglect when they failed to comprehensively assess and effectively monitor a resident with blood glucose levels registering over 400 milligrams per deciliter (mg/dL) (normal blood sugar levels are considered to be between 70mg/dL to 100 mg/dL) over two days, accurately notify the physician of the resident's medical status to ensure necessary care and services were implemented to treat the resident, and to identify the seriousness of the resident's change in medical status and the need to immediately initiate emergency medical services (EMS) when the resident was identified as nonresponsive. EMS was not notified until hours after the resident was first observed as nonresponsive by a physical therapy staff member. Resident #22 was assessed by EMS with an elevated heart rate of 140 beats per minute (bpm) (a typical resting heart rate for adults is between 60 and 100 bpm), respirations in the 40s breaths per minute (a normal respiratory rate is between 12 and 20 breaths per minute), and with a continued reading of a blood glucose level more than 400 mg/dL at time of transport by EMS. An Emergency Department (ED) physician assessment indicated Resident #22 was diagnosed with sepsis (a life-threatening complication of an infection) briefly explain and hyperglycemia. (Hyperglycemia is a medical condition in which the body's blood glucose level is higher than normal. High blood glucose happens when the body has too little insulin or when the body can't use insulin properly.) This was for one (Resident #22) of five residents reviewed for neglect. Immediate jeopardy began on 7/10/2024 when staff neglected to provide the necessary care and services to Resident #22 when she was identified as having a blood glucose reading of over 400 mg/dL. Immediate Jeopardy was removed on 9/9/2024 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Findings included: Resident #22 was originally admitted to the facility on [DATE] with multiple diagnoses some of which included dementia, type 2 diabetes mellitus, schizoaffective disorder, major depressive disorder, and hypertension. Resident #22 was readmitted to the facility on [DATE] after a hospitalization for the diagnoses of sepsis, urinary tract infection, and hydronephrosis. (Hydronephrosis is a medical condition characterized by excess fluid in a kidney due to blockage in the tube that connects the kidney to the bladder.) Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #22 was assessed as having adequate hearing and vision with clear speech. Documentation on the same assessment indicated Resident #22 was usually understood and usually had the ability to understand others. Resident #22 was coded as having the diagnosis of type 2 diabetes mellitus and received insulin injections for 7 days of the assessment period. Documentation on the care plan initiated on 6/22/2024 revealed a care plan description of Resident #22's risk for hypo/hyperglycemia and a diagnosis of diabetic retinopathy relative to a diagnosis of diabetes mellitus. One of the interventions was to observe signs and symptoms of hypo/hyperglycemia such as sweating, tremor, pallor, nervousness, headache, double vision, confusion, and or lack of coordination. Additional interventions were to perform blood glucose monitoring and medication/insulin as ordered. Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive Novolog insulin solution to be injected subcutaneously (applied under the skin) three times day at 8:00 AM, 12:00 PM, and 4:00 PM per the following sliding scale: If the blood glucose level was 201 to 250 administer 4 units; 251 to 300 administer 6 units; 301 to 350 administer 8 units; 351 to 400 administer 10 units; greater than 400 call the physician. Novolog is a fast-acting insulin used to treat high blood glucose for people with diabetes. Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive 5 units of Semglee insulin solution to be injected subcutaneously one time a day at 8:00 PM for hyperglycemia. Semglee is a long-acting insulin used to treat high blood glucose levels for people with diabetes. Documentation on the July Medication Administration Record (MAR) for Resident #22 revealed on 7/9/2024 the blood glucose level was 399 and Medication Aide (Med Aide) #5 administered ten units of insulin at 6:22 PM. Med Aide #5, an agency employee, was interviewed on 9/5/2024 at 1:08 PM and revealed the following information. Med Aide #5 confirmed she did take the blood glucose reading of 399 on 7/9/2024 and that she did not administer insulin to Resident #22. Med Aide #5 did not recall who the licensed nurse was who was assigned to help her perform medication administration tasks out of her scope of practice on 7/9/2024. Med Aide #5 explained when she put the blood glucose reading into the electronic MAR, the administration of the insulin would also incorrectly go under her name. Med Aide #5 indicated she had to trust that the licensed nurse, to whom she reported the blood glucose level of Resident #22, would administer the correct insulin dose, document the administration, and notify a physician of any concerns if needed. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin as ordered to Resident #22 on 7/9/2024 at 8: 24 PM. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or received Novolog insulin as ordered at 8:00 AM on 7/10/2024. Med Aide #4, an agency employee, was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 revealed the following information. On the morning of 7/10/24 she was assigned for the 7:00 AM to 7:00 PM shift to the hallway which Resident #22 resided. Med Aide #4 was told Nurse #4 took care of administering medications for several people during the 7:00 PM to 7:00 AM shift ending on 7/10/2024. Resident #22 was one of those people who Nurse #4 told Med Aide #4 she had already administered the morning medications to. Med Aide #4 stated she expected Nurse #4 to document on the MAR the medications she was told had already been administered as an explanation for why there was no documentation of the Novolog insulin for Resident #22 at 8:00 AM on 7/10/2024. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered 10 units of Novolog insulin on 7/10/2024 at 1:43 PM to Resident #22, one hour and 43 minutes after the scheduled administration time. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or was administered Novolog insulin as ordered at 4:00 PM on 7/10/2024. Med Aide #4, an agency employee, was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 relayed the following information. Med Aide #4 explained that she could not remember which licensed nurse was assisting her on 7/10/2024 and confirmed she did not administer Novolog insulin to Resident #22 on 7/10/2024 at 1:43 PM. Med Aide #4 thought the licensed nurse, assisting her on 7/10/24, was Unit Manager #2. On 7/10/2024 the blood glucose level for Resident #22 read as HI or above 400 on the glucose monitor. (A reading of HI on a glucometer means the reading is above the level readable by the glucometer.) The licensed nurse who was assisting Med Aide #4 was told the blood glucose monitor was reading above 400 and the physician needed to be called. The licensed nurse told Med Aide #4 the physician ordered 12 units of Novolog insulin to be administered to Resident #22 and to keep checking the blood glucose level every hour. Med Aide #4 kept checking the blood glucose level every hour and reported to the licensed nurse the reading was still registering as above 400 mg/dL. Med Aide #4 thought the licensed nurse was going to document everything and take care of the 4:00 PM scheduled Novolog insulin administration on 7/10/2024 because of the blood glucose readings that were over 400 mg/dL, requiring a physician to be notified. Unit Manager #2 was interviewed on 9/10/2024 at 8:21 AM. Unit Manager #2 revealed the following information. Unit Manager #2 did recall Med Aide #4 contacting her about an elevated glucose level for Resident #22 on 7/10/2024. Unit Manager #2 revealed she assessed Resident #22 and thought she was dehydrated but was arousable and able to drink fluids. Unit Manager #2 stated she was very busy on 7/10/24, in addition to being the unit manager, the only registered nurse in the building, doing wound care, and admitting multiple residents, leaving her with little time for adequate coverage of the Med Aides in the building. Unit Manager #2 revealed she thought she sent a text to the physician for Resident #22 informing him of the elevated blood glucose levels on 7/10/2024. Unit Manager #2 stated she trusted the judgement of Med Aide #4 and felt she communicated effectively if she needed any assistance. Unit Manager #2 could not recall specifically what interventions were put in place on 7/10/2024 other than administration of insulin and fluids but would trust the recollections of Med Aide #4. Unit Manager #2 revealed she kept a small notebook with notes on which residents she had to go back and complete documentation on as a late entry. Unit Manager #2 thought perhaps Resident #22 having elevated blood sugars was one of those residents and she forgot to go back and document. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin as ordered to Resident #22 on 7/10/2024 at 10:56 PM. There was no documentation in the electronic medical record of Resident #22 that any additional interventions were taken for the elevated blood glucose reading on 7/10/2024. There was no documentation on the July MAR Resident #22 had a blood glucose level taken or was administered Novolog insulin as ordered at 8:00 AM on 7/11/2024. The facility nursing schedule dated 7/11/2024 indicated Nurse #7 was assigned to the hallway for which Resident #22 resided for the 12 hour day shift (7:00 AM to 7:00 PM). Nurse #7 was interviewed on 9/5/2024 at 2:37 PM. Nurse #7 stated she was an agency nurse who only worked at the facility on one occasion and that was 7/11/2024. Nurse #7 stated she did not recall what hall she was assigned to. Nurse #7 stated when she arrived at 7:00 AM on 7/11/2024, the scheduler handed her a stack of paper MARs and told her to go to the hall to begin the medication pass. Nurse #7 explained she was told she would not have access to the electronic medical record system. Nurse #7 revealed it was chaos, but she stayed. Nurse #7 further explained that at 2:30 PM she was approached by the Interim Director of Nursing (DON) with the electronic medical record system login information she needed and another stack of papers for a new admission she was expected to process. Nurse #7 said she handed the new admission paperwork back to the Interim DON and told her she wasn't doing it. Nurse #7 revealed she had never returned to the facility. Med Aide #4 was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 stated she was assigned on 7/11/2024 for the 7:00 AM to 7:00 PM shift to another hall next to the hall which Resident #22 resided. Med Aide #4 revealed everything was a mess on the hallway which Resident #22 resided because there was an agency nurse (Nurse #7) who was trying to figure out the paper MAR and she was not giving medications. Med Aide #4 revealed the agency nurse (Nurse #7) left and was put on the do not return list. Documentation on the July MAR revealed Med Aide #4 obtained a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 11:47AM to Resident #22. Documentation on a physical therapy treatment encounter note for Resident #22 written by Physical Therapy Assistant (PTA) #1 on 7/11/2024 at 3:58 PM revealed, PTA facilitated that [Resident #22] get [out of bed] for the purpose of attempting goals. [Resident #22] responded [by demonstrating] extreme lethargy, incoherent mumbling, [nonresponsive] pupils/eye movement to bright light. PTA attempted to have [Resident #22] sit [on edge of bed] with [Resident #22 [demonstrating] inability to arise from sleep/difficulty to hold head. Nursing [Med Aide #4], DON, [Physical Therapist/Occupational Therapist] notified regarding [Resident #22's] decrease in status. Continue [with plan of care.] An interview was conducted with PTA #1 on 9/6/2024 at 4:45 PM. PTA #1 revealed the following information. PTA #1 stated she did not recall the exact time she went to see Resident #22 on 7/11/2024. PTA #1 confirmed she found Resident #22 in a nonresponsive condition on that day, so she went to the Med Aide on the hall, the interim DON, the Physical Therapist, and Occupational therapist to let them know of her concern for Resident #22. Documentation on the July MAR revealed Med Aide #4 took a blood glucose level of 400 mg/dL and administered ten units of Novolog insulin on 7/11/2024 at 4:51 PM. Med Aide #4 was interviewed on 9/6/2024 at 1:54 PM. Med Aide #4 confirmed she took the blood glucose readings for Resident #22 on 7/11/2024 at 11:47 AM and 4:51 PM. Med Aide #4 revealed that some of the blood glucose readings for Resident #22 were actually registering as HI or over 400 mg/dL while at least one of the readings she documented on the MAR on 7/11/2024 was actually 400 mg/dL. Med Aide #4 revealed the MAR did not allow Novolog insulin to be checked off as administered unless an actual number was entered into the MAR for the blood glucose reading. Med Aide #4 stated she had to put in 400 mg/dL although the reading may have been over 400 mg/dL. Med Aide #4 confirmed she told the licensed nurse who was assisting her on 7/11/2024 for the 12:00 PM and 4:00 PM administration time for the Novolog insulin, that the blood glucose levels were continuously HI. Med Aide #4 explained the licensed nurses were going into the MAR after she documented the blood glucose reading and using her login credentials to document the administration of insulin. Med Aide #4 was told by the licensed nurse on 7/11/2024 the physician had been contacted and ordered for Resident #22 to be monitored. Med Aide #4 did not recall who the licensed nurse was. Med Aide #4 confirmed PTA #1 informed her of concerns of the lack of response from Resident #22. Med Aide #4 stated she did tell the licensed nurse of what PTA #1 had said. Med Aide #4 stated she informed Unit Manager #2 and sent a text message to the interim DON about the continued blood glucose readings of over 400 mg/dL for Resident #22. Med Aide #4 stated she got a text message back from the interim DON that she would take care of it. Med Aide #4 stated that in report at the end of her shift on 7/10/24 and 7/11/24 she let Nurse #4 know Resident #22 was continually having blood glucose readings of over 400 mg/dL. Med Aide #4 indicated Nurse #4 did not seem to care, telling her that on the shift, 7:00 PM to 7:00 AM, when Nurse #4 worked, the blood glucose readings for Resident #22 were in the 200's mg/dL. Med Aide #4 stated, It just didn't make any sense to me but only the nurses can call the doctor. An interview was conducted with the responsible party (RP) for Resident #22 on 9/3/2024 at 3:42 PM and the following information was provided. On 7/8/2024 the RP checked on Resident #22 before going out of town and she was okay. The RP heard nothing all week from the facility. On 7/11/24 around 7:30 PM to 8:00 PM she saw she had several missed calls on her phone. She then picked up on the next one. It was from a private number. The person on the phone did not identify themselves but told the RP, You need to come now and check on your mother. It is an emergency. She needs to be sent out. The RP did not know what was going on because the facility did not notify her that Resident #22 was sick. The RP called another family member who was local to the facility and asked him to go to the facility to see Resident #22. The family member arrived at the facility around 8:30 to 8:45 PM to find Resident #22 was not responding. Nurse #4 walked into the room with a blood glucose monitor and said the doctor ordered Resident #22 to receive insulin, to monitor her blood glucose level, and call the doctor back in two hours. Since Resident #22 was not responding the family member insisted that Resident #22 be sent to the emergency room and finally Nurse #4 called emergency medical services (EMS). Later that night the interim DON called the RP wanting to know who had called her from the facility to let her know Resident #22 was not well. The RP stated she did not know who the anonymous phone caller was, but she was grateful she was contacted as it may have saved the life of Resident #22. The RP talked to the (former) Administrator about her concerns and the (former) Administrator informed the RP that the facility had learned that a physical therapy staff member had noted a change in the resident earlier that day. The (former) Administrator maintained that they did not have to let the family know if Resident #22 had elevated blood glucose levels, which did not make sense to her. If she had known that Resident #22's blood glucose levels were running high for several days she would have wanted her sent to the hospital to be checked. The RP felt the resident had been neglected and she had talked to the (former) Administrator about all her concerns. Documentation in the physician orders revealed an order dated 7/11/2024 at 7:00 PM for Resident #22 to be administered ten units of Humalog insulin solution to be injected subcutaneously one time only for a blood glucose exceeding 400 mg/dL and contact the physician in two hours. Humalog insulin is a fast-acting insulin which is absorbed quickly and starts working in about 15 minutes after injection to lower blood glucose levels. There was no documentation on the July MAR that the order for Humalog insulin was administered to Resident #22 on 7/11/2024 after 7:00 PM. Documentation on the July MAR revealed Nurse #4 administered Semglee insulin to Resident #4 on 7/11/2024 at 8:58 PM. Documentation in the physician orders revealed an order dated 7/11/2024 at 9:00 PM for Resident #22 to be administered ten units of Novolog insulin solution subcutaneously one time for blood glucose exceeding 400 mg/dL and contact the physician in two hours. There was no documentation on the July MAR that the one-time order for Novolog insulin was ever administered to Resident #22 on 7/11/2024 after 7:00 PM. There was no other documentation in the electronic medical record of any vital signs taken of Resident #22 on 7/11/2024. Documentation in the nursing notes for Resident #22 dated 7/12/2024 at 9:48 AM by Nurse #4 revealed, Physician contacted due to blood glucose exceeding 400 [mg/dL] and order received from physician to administer 10 [units] of Humalog or Novolog and report back after 2 hours. After 2 hours, resident blood [glucose] reading still exceeded 400 [mg/dL] and physician made aware of results. Family arrived and RP requested for resident to be sent to [emergency room] for evaluation. Physician made aware and order received to send resident to [emergency room]. [Director of Nursing] made aware. An interview was conducted with Nurse #4 on 9/5/2024 at 6:04 PM. Nurse #4 relayed the following information and timeline of events for Resident #22 on the evening of 7/11/2024. Nurse #4 started her 7:00 PM to 7:00 AM shift at 7:00 PM on 7/11/2024. Nurse #4 received the information in a nursing report from Med Aide #4 that the blood glucose level of Resident #22 was above 400 mg/dL on the 4:00 PM medication pass. Nurse #4 denied she had any knowledge of the blood glucose level of Resident #22 being at or above 400 mg/dL for several shifts. Nurse #4 stated she assessed Resident #22 and took her vital signs at the start of her shift. Nurse #4 revealed the blood glucose level of Resident #22 was registering as HI or over 400 mg/dL on the glucometer, a device to measure blood glucose levels. Nurse #4 revealed the vital signs of Resident #22 were fine, so she called the on-call physician. Nurse #4 stated she received an order from the physician to administer 10 units of fast acting insulin to Resident #22 and call the physician back in two hours. Nurse #4 stated she went back to check on Resident #22 again at 9:00 PM and all her vital signs were fine. Resident #22 did not have a temperature, elevated blood pressure, or an elevated heart rate. Nurse #4 stated her blood glucose level was still registering as HI or above 400 mg/dL on the glucometer. Nurse #4 was adamant Resident #22 was fine and was responsive. Nurse #4 related that when she pricked the finger of Resident #22 with the lancet, the resident looked at her and rolled her eyes. Nurse #4 stated the family of Resident #22 arrived at the facility stating they received a phone call from an unknown caller telling them something was wrong with Resident #22, and she needed to be sent to the emergency room. The family of Resident #22 looked at Resident #22 and demanded she be sent to the emergency room. Nurse #4 stated she did not know who called the family because the breathing and vital signs for Resident #22 were normal. Nurse #4 reported she was about ready to call the physician because of the elevated blood glucose reading, so she called the physician, and the physician agreed Resident #22 could be sent out per the family wishes. Nurse #4 relayed that she did all her documentation for the residents at the end of her shift so that all the events of the shift for each resident could be documented, for an explanation for why her nursing note for Resident #22 was dated 7/12/2024, the day after Resident #22 discharged from the facility. An interview was conducted with the interim DON on 9/5/2024 at 1:58 PM. The interim DON stated she was not made aware of any concerns with the blood glucose levels of Resident #22 until the RP called her on the evening of 7/11/2024 at approximately 8:00 PM or 8:30 PM. The interim DON was told by the RP of a phone call she received from a facility staff member telling her Resident #22 was very ill and needed to be sent to the hospital. The interim DON relayed she called Nurse #4 and was told Resident #22 was still at the facility and was fine. The interim DON further revealed Nurse #4 had explained the following interventions for Resident #22. An assessment had been completed by Nurse #4 revealing an elevated blood glucose level, lethargy, vital signs were fine, the physician was called for orders, and Resident #22 was responsive. The interim DON stated she knew the blood glucose level of Resident #22 was high in the moment on the evening of 7/11/2024 but she was not aware the blood glucose level had been HI over several shifts. Documentation on an Emergency Medical Services (EMS) report dated 7/11/2024 revealed 911 was called at 9:17 PM and arrived at room of Resident #22 at 9:37 PM. The following information was revealed in the EMS report. Upon arriving at the scene, the facility staff stated Resident #22 had been having an elevated blood glucose level all day and had been alert but not acting like herself. The facility staff also told EMS they had been giving Resident #22 insulin as instructed by the resident's physician with no changes in the reading level of HI on the glucose monitor. EMS noted Resident #22 had a glucose reading of HI on their glucose monitor as well. EMS documented Resident #22 as having a heart rate of 140 with respirations in the 40s. Once in the ambulance, Resident #22 remained unresponsive. Documentation on a hospital record dated for a 7/11/2024 admission revealed Resident #22 was diagnosed with sepsis, hyperglycemia, altered mental status, acute renal failure, dehydration, and a urinary tract infection in the emergency room. Resident #22 was discharged from the hospital on 7/24/2024 into the care of the RP with home health services, per the RP's request. An interview was conducted with MD #2, the physician for Resident #22, on 9/9/2024 at 1:12 PM. MD #2 stated he could not recall if he was notified of the elevated blood glucose levels of Resident #22 on 7/9/2024, 7/10/2024, or 7/11/2024. MD #2 explained that if he had been notified of elevated blood glucose levels for Resident #22 during normal business hours, he would have ordered a change in the amount of fast-acting insulin to be administered and requested a call back if there was no change after continuous monitoring of the resident. MD #2 indicated that if those orders did not exist on 7/10/2024 or 7/11/2024 during the day shift then it was likely he was not notified. MD #2 stated he did not recall receiving a phone call on the evening of 7/11/2024 from Nurse #4, but he received phone calls of that type routinely making it difficult to recall a specific phone call of that type for a resident. MD #2 stated that a blood glucose level of 400 mg/dL was not good, but having a blood glucose level of 400 mg/dL was an isolated event for this resident making it likely an underlying medical condition was occurring for which he would have had to figure out. The facility's medical director was interviewed on 9/9/24 at 4:19 PM and details of how the staff had failed to respond to Resident # 22's multiple readings of high blood glucose readings and unresponsiveness prior to EMS transport were discussed with the medical director. The medical director reported facility staff had not shared with him any incidents which would indicate Resident # 22 had been neglected and he was unaware of what had transpired with Resident # 22. On 9/9/24 at 5:04 PM the facility Administrator and Corporate Nurse Consultant were notified of Immediate Jeopardy based on findings related to Resident # 22. On 9/10/24 the facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #22 was admitted to the facility on [DATE] and discharged on 07/11/2024. Between the original admission and discharge, she was readmitted on [DATE]. The most recent readmission, she was readmitted with diagnoses that included: Type 2 diabetes with diabetic retinopathy without macular edema (a complication of diabetes that can cause vision loss and blindness), schizoaffective disorder, dementia, chronic embolism (long-term condition where one or more blood clots block the pulmonary arteries), and thrombosis of distal lower extremity (a blood clot condition that forms within the deep veins, usually of the leg, but can occur in the arms). Review of Resident #22's Medication Administration Records (MAR), indicates; on 7/10/24 at 1:43pm the medication aide (MA #4) notified Unit Manager #2 that Resident #22 had blood glucose levels registering over 400. No evidence that the physician was notified. Resident #22's MAR indicates that Resident #22 received 10 units of Novolog insulin at 1:43pm. Further review of Resident #22's MAR indicates; on 7/11/2024, at 11:47 am, Resident #22's blood glucose was documented to be 400 and 10 units of fast-acting insulin were administered, no evidence that the physician was notified. Review of the Physical Therapy Assistant documentation on 7/11/24 at 3:38 PM indicated the resident was non-responsive, and the Director of Nursing was notified. No documentation of actions taken, no evidence that the physician was notified. The Director of Nursing who was informed is no longer working at the facility. On 7/11/24 at 4:51pm blood glucose documented by MA #4 to be 400. The MAR indicates Resident #22 received 10 units of Novolog insulin. No indication that the physician was notified, or anything else was done. Review of progress notes documented on 7/12/2024 (late entry for 7/11/2024), in Resident #22's medical records indicate (in part); Nurse #4 contacted physician due to Resident #22 blood glucose exceeding 400. An order was received from the physician to administer ten units of Humalog or Novolog and report back after 2 hours. After two hours, Resident #22's blood glucose reading still exceeded 400 and the physician made aware of results, the note added. Resident #22's family arrived and requested that Resident #22 to be sent to the hospital for evaluation. The physician made aware, and the order received to send resident to hospital, documentation concluded. A phone interview was conducted on 09/07/2024 by the Assistant Director of Nursing. Nurse #4 indicated; she contacted physician around 7:10pm on 7/11/2024 due to Resident #22's blood glucose exceeding 400. Nurse #4 added she received an order to administer ten units of Humalog or Novolog and report back after 2 hours. Nurse #4 indicated that she recalled Administering 10units of Novolog to Resident #22 per physician order. Nurse #4 further added that, at approximately 9:00pm, she rechecked Resident #22's blood glucose, the reading still exceeded 400. She added the physician was made aware of the results at approximately 9:03pm. Per Nurse #4, Resident #22's family arrived at approximately 9:05pm and requested for Resident #22 be sent to the hospital. The physician was made aware of the request at approximately 9:10pm, and the order was received to send the resident to hospital, Nurse # 4 contacted EMS at 9:17pm, interview concluded. EMS arrived on scene at 9:32pm. Resident #22 was still non-responsive when EMS arrived. Per EMS report, Resident #22 was found with an elevated heart rate of 140, respirations in the 40s, and with a continued reading of a blood sugar in excess of 400 at time of transport. Resident #22 was sent to the hospital for further evaluation and treatment, Resident #22 left the facility at approximately 9:53pm. Resident #22 is no longer in the facility. No other actions taken. The Governing body led by the [NAME] President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis on 09/06/2024, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. For Resident #22, the Root Cause Analysis (RCA) identified the alleged noncompliance resulted from the failure of the facility employee (Nurse # 4) to follow the professional standard of practice on managing repeated episodes of hyperglycemia for Resident #22 who was non-responsive on 7/11/2024. The RCA further identified that the facility failed to have a system in place medication aides to be informed of the licensed nurse responsible to oversee them while on duty. The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring. On 7/11/2024, the former Administrator completed an initial report to the State agency and completed the investigation on 7/15/2024 for Resident #22. The allegation was unsubstantiated. Per investigation report completed on 7/15/2024, the allegation for Resident #22 was not reported to law enforcement and Adult Protective Services (APS). The former Administrator is no longer employed at the facility. On 09/09/2024 the new Administrator has been educated by the [NAME] President of Operation on reporting requirements to include reporting to Law enforcement and APS. Clinical assessments of all current residents in the facility were completed on 09/07/24 by the Director of Nursing, Assistant Director of Nursing, and/or Unit coordinator (#1 or #2) to identify any other resident with the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 21 was originally admitted to the facility on [DATE]. The resident's diagnoses included in part a diagnosis of diabetes, dementia, and a history of heart attack and cancer. Review of Resident # 21's 4/12/24 quarterly Minimum Data Set assessment revealed the resident was cognitively impaired. He was able to clearly speak and make himself understood. He was also able to eat with supervision only. The resident was also coded to be a diabetic and had required insulin for seven days in the assessment period. Review of June 2024 monthly orders and the June 2024 MAR (medication administration record) revealed the following: Resident # 21 had an order, which originated on 3/25/23, for Humalog 100 units/ml give 5 units under the skin with breakfast. (Humalog is a fast-acting insulin). Resident # 21 had an order, which originated on 11/16/23, for Humalog 100 units/ml give 10 units under the skin every day at 12 PM. Resident # 21 had an order, which originated on 11/16/23, for Humalog 100 units/ml give 7 units under the skin every day at 4:30 PM. Resident # 21 had an order, which originated on 4/18/24, for Levemir 70 units every hour of sleep. (Levemir is a long acting insulin). Additionally Resident # 21 had orders for blood glucose checks and sliding scale insulin coverage with Humalog Insulin four times per day. The sliding scale insulin dosage was noted be as follows: 201-250 4 units; 251-300 6 units; 301-350 8 units; 351 to 400 10 units; call MD for greater than 400. According to the June 2024 MAR the blood glucose checks were scheduled for 6:00 AM; 11:30 AM; 4:30 PM; and 9:00 PM. The resident's MAR was blank for the reading on 6/28/24 at 6:00 AM. Resident # 21 also had an order to follow standing orders. Review of standing orders revealed emergency measures would be initiated by a licensed nurse immediately when either a routine or stat (right away) CBG (capillary blood glucose) indicates hypoglycemia (low blood glucose). The standing orders further directed for a blood glucose less than 60 the following should be done: If the resident had no renal failure and could take oral food, the resident would be given 15 grams simple carbohydrate (1 tube instant glucose (buccal) or 1 AMP (ampule) Glucagon IM (intramuscularly). Then the resident was to be given protein (4 ounces of milk or 1 tablespoon of peanut butter) and carbohydrate (6 saltines or 3 graham crackers). The blood glucose was to then be checked again in 15 minutes and if the response was inadequate the treatment was to be repeated. On 6/28/24 at 9:54 AM Nurse # 4 documented the following entry. Resident was alert and responding normally per his baseline at HS (hour of sleep). Resident was hot to the touch and vital signs measured. Resident noted to have temperature of 99.8. Resident received PRN (as needed) Tylenol with scheduled medications and during follow up resident's temperature had fallen to 98.8. At 0600 (6:00 AM) resident's temperature remained within normal ranges. On 6/28/24 at 1:19 PM Unit Manager # 2 documented the following late entry which indicated when she was called to the room on that date emergency medical staff were with the resident. The entry did not note the time she had been called to the room. The nursing entry read, Late entry for 06/28/2024. Nurse called to resident's room at this time because staff noted resident not responsive and difficult to arouse. EMT (Emergency Medical Technician) present and resident noted in bed with eyes closed and lethargic. VS (vital signs) 97.6-81-16 98/60 82% oxygenation on room air. Resident given IV glucose prior to transport and now being sent to ER for evaluation. Physician notified at this time. The day following the resident's 6/28/24 transfer to the hospital Nurse # 4 also entered a nursing entry. Specifically, on 6/29/24 at 9:31 AM Nurse # 4 documented the following nursing entry. This writer was made aware that residents blood glucose was measured at 33 by med aides on duty. Upon entering the room, resident was noted to be pale and lethargic. Resident unable to drink orange juice at that time but tolerated sugar mixed in applesauce. Resident blood glucose measured again and read 56. RN Unit Manager on duty arrived to room to assess resident. EMS arrived 9:06 AM and was received report from RN Unit Manager on duty. Review of EMS (emergency medical system) records revealed the following information. EMS was called on 6/28/24 at 8:56 AM, on the scene at 9:05 AM, and at Resident # 21's side at 9:07 AM. At 9:11 AM the EMS records showed the resident was unresponsive upon their arrival and he had a blood glucose level of 38. Once an IV with dextrose was begun the resident became alert and talking. They were unable to obtain his temperature reading. The resident was transferred to the hospital for evaluation. Review of Resident # 21's hospital admission history and physical, dated 6/28/24, revealed the physician noted the EMS crew had been summoned to the facility when the resident was found to be profoundly hypoglycemia with a blood glucose reading of 30. The history and physical noted the resident was found to have lactic acidosis related possibly to liver disease or hypoglycemia. (Lactic acidosis is a build- up of lactate acid in the bloodstream which is normally metabolized and can contribute to organ dysfunction). Following hospitalization and treatment, Resident # 21 returned to the facility on 7/5/24. On 9/3/24 at 10:55 AM MA (Medication Aide) # 3 was interviewed and reported the following. On 6/28/24 she arrived at work during the morning. MA # 4 had asked for help as she (MA # 3) was coming on duty. MA # 4 informed her that the assigned Nurse Aide had let her (MA # 4) know that Resident # 21 was gurgling and everything and she needed help. She (MA # 3) went immediately, and she checked the resident's blood glucose. It was 33. She called the ADON (Assistant Director of Nursing) who told her to call 911. As a medication aide, she thought she could not call 911. Therefore, she ran to get Nurse # 4, who was the night shift nurse and still at work. She told Nurse # 4 that she needed to call 911. At that time Nurse # 4 was still in the medication room. Nurse # 4 did not move to do anything, so she ran to tell another nurse (Nurse # 5). She then went back to the room and started to give the resident some sugar and orange juice under his tongue. She had also asked Nurse # 4 to get some Glucagon, but she never came to help before EMS arrived. When EMS arrived, she (MA # 3) was the only staff member in the room with the resident and he was not responding. Unit Manager # 2 came into the room after EMS arrived. When the Unit Manager arrived, she said that she had come because the ADON had texted her. MA # 3 did not understand why the ADON had texted when they needed help from the nurses right away. Once EMS came to the room, then Nurse # 4 came into the room. The paramedics started asking when Resident # 21's blood glucose was last checked and Nurse # 4 stated she had checked it at 6 AM. Resident # 21's roommate spoke up at that point and said that was not true, and he had been trying to tell someone that there was something wrong with his roommate. MA # 4 was interviewed on 9/5/24 at 12:06 PM and reported the following. On 6/28/24 during the breakfast time period Resident # 21's assigned NA (Nurse Aide) had let her know that the resident was not acting right and would not talk to the NA. At the beginning of the shift, she had not been told who the nurse was covering her to conduct assessments and things she could not complete as a MA. She went into Resident # 21's room and checked his blood glucose. It was low. She did not recall the exact number. MA # 3 was there and tried to help her. They saw that Nurse # 4 was still there from night shift. They asked Nurse # 4 if there was some glucose that could be given to Resident # 21 and there was none. Nurse # 4 did not come right away to help them, and she did not recall if it was before EMS or after EMS got there that she did come. When she did come, Nurse # 4 did not lay hands on the resident or assess him. She stood and watched as she and MA # 3 were trying to give him some sugar with applesauce, but he was not able to swallow. She recalled that Unit Manager # 2 did come to the room at some point, but she thought it was after EMS arrived. She was at the door when EMS arrived to let them in and the only person in the room with the resident was MA # 3 that she recalled when the EMS team arrived. Interview with the ADON on 9/5/24 at 1:18 PM revealed she had been the acting DON at the time. She had been aware the resident's blood glucose was low, but she thought the staff had worked together as a team. She did not recall getting a phone call from MA # 3 or that she told MA #3 to call 911. There was supposed to be glucagon on the crash carts for emergencies and in the back up medication supply from the pharmacy. She thought that Nurse # 4 helped MA # 4 try to give Resident # 21 a paste of sugar and applesauce (a mixture of sugar in applesauce) while Unit Manager # 2 went to find glucagon. She did know that there had been a problem with them not finding the glucagon, but she thought it was because they had not had an emergency in a while and just had not found it. The glucagon had been present in the facility. She was not aware that the roommate alleged he had tried to tell someone earlier that the resident was not right or that both MA # 3 and MA # 4 were reporting that Nurse # 4 did not come right away. She had not talked to MA # 4 about the situation and did not know she had been involved. The ADON also reported that the resident's roommate could seem as if he was alert, but he was confused at times. (A review of Resident #21's roommate's Minimum Data Set assessments, dated 5/25/24 and 8/25/24, revealed Resident # 21's roommate was cognitively impaired.) Nurse # 4 was interviewed on 9/6/24 at 7:31 AM and reported the following information. She had already counted off narcotics on 6/28/24 with MA # 4 and finished her night shift. She was still in the medication room documenting. MA # 4 came to get her and let her know that Resident # 21 was clammy. She went with MA # 4 to check Resident # 21's blood glucose. It was low. She did not recall the value. She described to MA # 4 what glucagon looked like on the cart and asked her to get it for her. MA # 4 could not find glucagon on the medication cart. At some point Unit Manager # 2 came also and they were both in and out of the room. They did not leave the resident alone with the medication aides. She went to the emergency medication supply which was located on the opposite side of the building at Station # 1. (Resident # 21 resided on Station # 2). When she returned with the glucagon, which she found in the emergency supply, she then found that the first responders and paramedics were in the room and giving other interventions for the low blood glucose. Therefore, she did not give the glucagon she had obtained. Nurse # 4 further reported Resident # 21 had slept during the night before the incident of low blood glucose. She had checked his blood glucose at the due time of 6:00 AM and it was above 100. When she had been called by MA # 4 to come help, she had been finishing her documentation and may have forgotten to chart it. She did not recall Resident # 21's roommate speaking up to say that he had been trying to tell someone that there had been something wrong with the resident before that time. Unit Manager # 2 was interviewed on 9/4/24 at 8:39 PM and reported the following. She had arrived to Resident # 21's room on 6/28/24 because she got a text from the ADON that they needed assistance. The ADON was not in the facility at the time she texted for her (the Unit Manager) to go to the room. The resident was barely responding but was breathing when she arrived. He could not talk and could not open his eyes. He was diaphoretic (sweating heavily). There was no glucagon in the entire facility to give to the resident according to Unit Manager # 2. She thought MA # 3 had been confused about her role as what she could do as a medication aide. There had been directions at the nursing desk that the MAs were to call the ADON. That is why she thought MA # 3 called the ADON rather than activating some sort of emergency system in the facility. Nurse # 4 arrived in the room after the paramedics got to the room. The EMS crew started asking questions about what Resident # 21's blood glucose had been previously and how he had been. Resident # 21's roommate spoke up and said he had tried to tell someone that the resident was not acting like himself during the night. She Unit Manager # 2) arrived a couple minutes before the fire department and paramedic team. The resident did have vital signs, but she thought in a case such as what happened that a code should have been called by the staff to get help. Unit Manager # 2 also reported she no longer worked at the facility. Nurse # 5 was interviewed on 9/5/24 at 4:15 PM and reported the following information. She had been in the rehab unit on the morning of 6/28/24 and was talking to Nurse # 4 by phone. Nurse # 4 was in the medication room at the time on Station 2. She heard through the phone MA # 3 come to Nurse # 4 and tell her Resident 21's blood glucose was in the 30s. She knew Nurse # 4 got up from the chair because she could hear over the phone her sliding her chair back and the medication room door opening. Then MA # 3 came down to the rehab unit and asked her (Nurse # 5) to call 911. She (Nurse # 5) called 911. After talking to emergency medical services, she (Nurse # 5) then walked from the rehabilitation hall to the nursing desk at Station # 2. She looked down the hall but did not walk to Resident # 21's room. She saw Unit Manager # 2 and Nurse # 4 standing at the doorway of Resident # 21's room and knew they were there. She did not go to the room at that time, and she did not ever see them actually in the room. An attempt was made on 9/5/24 at 2:41 PM to talk to the Nurse Aide who was assigned to care for Resident # 21 on the night shift prior to Resident # 21 being transferred to the hospital on 6/28/24. The Nurse Aide could not be reached. An attempt was made on 9/5/24 at 2:43 PM to talk to the Nurse Aide who had been assigned on the day shift to Resident # 21 on 6/28/24. The Nurse Aide could not be reached. One of the paramedics who responded on 6/28/24 was interviewed on 9/5/24 at 10:52 AM and reported the following information. EMS had been summoned because the resident's blood glucose was 30. When they arrived, there was not a licensed nurse in the room with the resident and it took a hot minute for one to arrive. There was a Medication Aide with the resident, and she had been trying to get orange juice and sugar to him. The paramedic did not know what other specialized efforts had been made before they arrived. One of the nurses that arrived in the room after they got there identified herself as the house supervisor (Unit Manager # 2). She talked like she knew what was going on with the resident, but her words indicated otherwise because she commented that she did not know why the staff had not given him his insulin. That concerned him that she did not seem to realize that the problem was with the resident's blood glucose being low and not high. When they arrived, the resident was not at a life threatening state at that point, but his low blood sugar could have led to cardiac arrest. The EMS team went to work starting an IV in and getting his blood sugar to rise. Once they got his blood glucose up, they also found that there was a problem with his temperature reading. They went ahead and transported him to the hospital. He did recall there was some discussion in the room about Resident # 21's roommate speaking up about him not being checked but he (the paramedic) had not paid a lot of attention because they were focused on getting Resident # 21's blood glucose up, and he did not know if the roommate was alert and oriented to know what he was talking about. The Corporate Nurse Consultant was interviewed on 9/5/24 at 4:15 PM and reported the following information. It was a standard of medical practice to page for help when a resident was in an emergency situation so that multiple staff members could arrive. The resident did not have to be totally without signs of life for a code to be called. According to the Corporate Nurse Consultant a licensed nurse should have assessed the resident prior to EMS arrival and intervened per orders when the resident was not responding and with a low blood glucose. A pharmacist (Pharmacist # 1) was interviewed on 9/6/24 at 11:28 AM and reported the following. The facility has both the injectable glucagon and also glucagon in a gel form within their emergency medication supply. The pharmacy records showed the glucagon was in the medication emergency supply on the date of 6/28/24 and had not needed to be refilled by the pharmacy. There was no glucagon that had been signed out for Resident # 21 on 6/28/24 or any other resident. The first access to the entire emergency medication supply system was on 6/28/24 at 11:45 AM by the ADON. At that time, she had not removed glucagon. On 9/10/24 at 10:29 AM Pharmacist # 2 was also interviewed and reported she could access records which showed whether the drawer of the emergency medication supply with glucagon was actually opened in an attempt to remove the glucagon. This was because nurses had to log into the computer system for the emergency medications before they could tell which drawer the medication they needed was located. Once a nurse logged into the system, not all the drawers for all the medications opened. No one had logged into the emergency medication supply to access the drawers and remove any type of medication prior to the ADON logging into the system on 6/28/24. The facility's medical director was interviewed on 9/9/24 at 4:19 PM and details of how the staff reported they had responded to Resident # 21's hypoglycemic episode on 6/28/24 were discussed with the medical director. The medical director reported no one had shared any problems with him about the incident and he had been unaware of any failures on the facility's part to respond. On 9/6/24 at 5:44 PM the facility Administrator and Corporate Nurse Consultant were notified of Immediate Jeopardy based on findings related to Resident # 21 and Resident # 22. On 9/9/24 the facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: 1. Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. Between the original admission and readmission, he was discharged to the hospital on [DATE]. The most recent readmission, he was readmitted with diagnoses that included: Major depressive disorder, Type 2 diabetes with hyperglycemia, cirrhosis of liver, anxiety disorder, dementia, anemia, old myocardial infarction, atherosclerotic heart disease of native coronary artery without angina pectoris (a condition of chest pain or discomfort that happens when some part of the heart doesn't get enough blood and/or oxygen), spastic diplegic cerebral palsy (a neurological disorder that causes muscles to be overly toned), and metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain). Review of Resident #21's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 04/12/2024 indicated that Resident #21 had a Brief Interview of Mental Status (BIMS) score of six which suggests severe impairment in mental status. Review of progress notes documented on 6/29/2024 (late entry), regarding the event happened on 6/28/2024, documented by Nurse #4 in Resident #21's medical records indicated (in part) Nurse # 4 was made aware that Resident #21 blood glucose was measured at 33 by Medication Aide #3. Nurse #4 added, upon entering the room, resident #21 was noted to be pale and lethargic. Resident #21 was unable to drink orange juice at that time but tolerated sugar mixed in applesauce. Resident #21 blood glucose measured again and read 56. Unit Manager #2 arrived in the room to assess resident #21. Emergency medical services (EMS) arrived at approximately 9:05am, documentation concluded. No evidence that code blue (an announcement that indicates a resident is in critical condition and needs immediate medical attention). Nurse #4 did not administer Glucagon (synthetic hormone that works with other hormones and bodily functions to control blood glucose level), to Resident #21 per physician standing order. Phone interview was conducted by the Assistant Director of Nursing on 09/07/2024, Nurse #4 reported the following information: Nurse #4 indicated she documented the event on 6/29/2024 as a late entry for an event that happened on 6/28/24, She also added that, she recalled being notified of Resident #21's low blood glucose at approximate 8:30am on 6/28/2024, (initial reported time). After approximately three minutes of being notified, she entered Resident #21's room, Resident #21 was noted to be pale and lethargic, Nurse #4 added. Nurse #4 rechecked Resident #21's blood glucose approximately ten minutes after the initial report, blood glucose read 56. Nurse #4 added, Unit Manager #2 arrived in the room approximately fifteen minutes after the initial report to assess Resident #21. Nurse #4 added, Nurse # 5 contacted the Emergency medical services (EMS) at around 8:56 AM. EMS arrived at approximately 9:05am. Medication Aide #3 was in the room at the time when EMS arrived. Upon EMS arrival on 6/28/24 Resident #21's blood glucose reading was 38, Resident #21 was still nonresponsive at the time EMS arrived. The hospital records indicated the resident was profoundly hypoglycemic. Resident #21 was readmitted to the facility on [DATE]. Resident #21 was assessed by the Assistant Director of Nursing on 09/06/2024 for any clinical signs of hypoglycemia. No signs of hypoglycemia were noted. 2. Resident #22 was admitted to the facility on [DATE] and discharged on 07/11/2024. Between the original admission and discharge, she was readmitted on [DATE]. The most recent readmission, she was readmitted with diagnoses that included: Type 2 diabetes with diabetic retinopathy without macular edema (a complication of diabetes that can cause vision loss and blindness), schizoaffective disorder, dementia, chronic embolism (long-term condition where one or more blood clots block the pulmonary arteries), and thrombosis of distal lower extremity (a blood clot condition that forms within the deep veins, usually of the leg, but can occur in the arms). Review of Resident #22's Medication Administration Records (MAR), indicates; on 7/10/24 at 1:43pm the medication aide (MA #4) notified Unit Manager #2 that Resident #22 had blood glucose levels registering over 400. Resident #22's MAR indicates that Resident #22 received 10 units of Novolog insulin at 1:43pm. Further review of Resident #22's MAR indicates; on 7/11/2024, at 11:47 am, Resident #22's blood glucose was documented to be 400 and 10 units of fast-acting insulin were administered. Review of the Physical Therapy Assistant documentation on 7/11/24 at 3:38 PM the resident was non-responsive, and the Director of Nursing was notified. No documentation of actions taken. The Director of Nursing who was informed is no longer working at the facility. On 7/11/24 at 4:51pm blood glucose documented by MA #4 to be 400. The MAR indicates Resident #22 received 10 units of Novolog insulin. No indication that anything else was done. Review of progress notes documented on 7/12/2024 (late entry for 7/11/2024), in Resident #22's medical records indicate (in part); Nurse #4 contacted physician due to Resident #22 blood glucose exceeding 400. An order was received from the physician to administer ten units of Humalog or Novolog and report back after 2 hours. After two hours, resident #22 blood sugar reading still exceeded 400 and physician made aware of results, the note added. Resident #22's family arrived and requested that Resident #22 to be sent to the hospital for evaluation. The physician made aware, and the order received to send resident to hospital, documentation concluded. A phone interview was conducted on 09/07/2024 by the Assistant Director of Nursing. Nurse #4 indicated; she contacted physician around 7:10pm on 7/11/2024 due to Resident #22's blood glucose exceeding 400. Nurse #4 added she received an order to administer ten units of Humalog or Novolog and report back after 2 hours. Nurse #4 indicated that she recalled Administering 10units of Novolog to Resident #22 per physician order. Nurse #4 further added that, at approximately 9:00pm, she rechecked Resident #22's blood glucose, the reading still exceeded 400. She added the physician was made aware of the results at approximately 9:03pm. Per Nurse #4, Resident #22's family arrived at approximately 9:05pm and requested for Resident #22 be sent to the hospital. The physician was made aware of the request at approximately 9:10pm, and the order was received to send the resident to hospital, Nurse # 4 contacted EMS at 9:17pm, interview concluded. EMS arrived on scene at 9:32pm. Resident #22 was still non-responsive when EMS arrived. Per EMS report, Resident #22 was found with an elevated heart rate of 140, respirations in the 40s, and with a continued reading of a blood sugar in excess of 400 at time of transport. Resident #22 was sent to the hospital for further evaluation and treatment, Resident #22 left the facility at approximately 9:53pm. Resident #22 is no longer in the facility. No other actions taken. The Governing body led by the [NAME] President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis on 09/06/2024, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. For Resident #21, the Root Cause Analysis (RCA) identified the alleged noncompliance resulted from the failure of the facility employee (Nurse # 4) to follow the professional standard of practice on managing hypoglycemia for Resident #21 who was non-responsive on 6/29/2024. The RCA further identified that facility staff also failed to announce code blue indicating medical emergency to solicit assistance from other employees in the facility, failure to follow physician order to administer glucagon (synthetic hormone that works with other hormones and bodily functions to control blood glucose level), and failure for facility staff to understand that any employee can call Emergency Medical Services (EMS) for any emergencies in the facility. For Resident #22, the Root Cause Analysis (RCA) identified the alleged noncompliance resulted from the failure of the facility employee (Nurse # 4) to follow the professional standard of practice on managing repeated episodes of hyperglycemia for Resident #22 who was non-responsive on 7/11/2024. The RCA further identified that the facility failed to have a system in place medication aides to be informed of the licensed nurse responsible to oversee them while on duty. The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring. Clinical assessments of all current residents in the facility were completed on 09/07/24 by the Director of Nursing, Assistant Director of Nursing, and/or Unit coordinator (#1 or #2) to identify any other resident with the change condition that require medical attention. The clinical assessment focused on resident's vital signs to include, blood pressure reading, pulse, respiration rate, temperature, and/or presence of pain. The assessment also includes measuring blood glucose for the residents with diagnosis of diabetes with orders for blood glucose check. The attending physician will be informed by the Director of Nursing, Assistant Director of Nursing and/or Unit Coordinator #1 or #2) on any identified findings of a change in condition and appropriate measures to include, but not limited to activating emergency medical services if indicated. 100% audit of all current resident's blood glucose reading documented from 6/28/2024 to 09/07/2024 completed on 09/07/2024 and 09/08/2024, by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinator (#1 or #2) to identify any other documentation of a resident with episodes of hypoglycemia and/or hyperglycemia that was not addressed appropriately in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Any resident(s) identified with a change in condition, the Director of nursing will inform the physician for appropriate measures and or interventions and implement the interventions as ordered. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Effective 09/07/2024, facility employees will ensure residents received necessary care to include assessing, monitoring, addressing a change in condition, identify the seriousness of a change in condition, and recognize the need to initiate emergency medical services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This systemic modification will be accomplished by implementing the following measures: Effective 09/07/2024, licensed nurses will oversee care and services for each resident in the facility. A Nurse # 4 will be informed at the beginning of the shift, through the daily schedule, of his/her responsibility to oversee certified medication aide(s) if any. Effective 09/07/24, Director of Nursing, Assistant Director of Nursing, Unit Coordinator (#1 or #2), Weekend Supervisor, and/or Scheduling Coordinator will be responsible to update daily schedule for nursing staff (licensed nurses, medication aides, and certified nursing aides). The daily schedule will inform each nursing staff of their assignment and responsibilities to include responsibility for licensed nurses to oversee medication aides (if any). The Facility Administrator will educate Director of Nursing, Assistant Director of Nursing, Weekend Supervisor, Unit Coordinator #1/or #2 and Scheduling Coordinator. The education focused on the importance of ensuring a daily nursing schedule is completed and indicate the responsibility of each nursing staff to include the responsibilities of the licensed nurse to oversee the medication aides. This education will be completed by 9/8/2024. Any licensed nurses and/or medication aide not educated by 09/08/24 will not be allowed to work until educated. The Director of Nursing will complete this education for any newly hired, Assistant Director of Nursing, Weekend Supervisor, Unit Coordinator #1/or #2 and Scheduling Coordinator during the orientation process effective 9/8/2024. Effective 09/07/2024 the assigned licensed nurse will be responsible to provide necessary care to include assessing, monitoring, addressing a change in condition, identifying the seriousness of a change in condition, and recognizing the need to initiate emergency medical services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for their assigned residents, and/or those assigned to the medication aide under the nurse's supervision. Effective 09/07/2024, for residents with orders for blood glucose check; certified medication aides will obtain and document blood glucose reading in each resident's medical records, and inform a Nurse immediately, on any [TRUNCATED]