Based on record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 closed record (Resident #1) with diabetes. Failure to ensure residents receive treatment and care according to professional standards of practice related to blood glucose monitoring increases the risk of serious harm, impairment, or death. During the complaint survey, the team determined an Immediate Jeopardy (IJ) situation existed on 02/01/24 at 5:22 p.m. The IJ resulted from staff failure to recheck a resident's glucose [sugar] or take additional interventions after a test result of 61 mg/dL (milligrams per deciliter) on 01/13/24. Staff found Resident #1 unresponsive and could not be revived. * 02/01/24 at 4:03 p.m., the survey team contacted the State Survey Agency (SSA) to report the findings, discuss, and confirm the presence of IJ. * 02/01/24 at 5:22 p.m., the survey team notified the administrator and the director of nursing (DON) of the IJ situation, provided them with the IJ template, and requested they develop a plan for removal of the IJ. * 02/02/24 at 11:33 a.m., the DON emailed the IJ removal plan for the SSA to review. The removal plan contained the following: * For all diabetic residents with orders for blood sugar [BS] checks the facility revised the orders in the electronic medical record [EMR] so if the BS is less than 70 the nurse is prompted to complete required task interventions and complete a BS recheck 15 minutes after the intervention until the BS is greater than 70. The nurse will not be able to sign off the order until all required tasks are completed. The nurses will also be required to enter the BS result in the task before it can be signed off. * The facility updated the blood glucose protocol to incorporate these changes. * All nurses will be educated on this updated facility blood glucose protocol prior to working their next shift. * Added specific education for the blood glucose protocol to the nurse orientation checklist. * 02/02/24 at 11:35 a.m., the SSA reviewed and accepted the facility's removal plan for the IJ. * 02/02/24 at 11:43 a.m., the SSA notified CMS (Centers for Medicare & Medicaid Services) location of the presence of IJ and emailed the IJ template to CMS. * 02/05/23 at 5:05 p.m., the survey team verified the implementation of the facility's IJ removal plan. The deficient practice remained at a G scope and severity following the removal of the IJ. Findings include: Review of the facility policy and procedure titled Blood Glucose - Protocol if Abnormal occurred on 02/01/24. This policy, dated 05/17/23, stated, . Low glucose is considered below 70. For GLC [glucose] 60-70 - give 15 g [grams] CHO [carbohydrate] * 4 oz juice * 4 oz regular soda * 1 tablespoon sugar (4 packets), honey, jam or jelly * 5 or 6 pieces of hard candy * 6 large Jelly beans, 5 gum drops, 12 [sic] gummi bears, 4 Starburst, 1.S [sic] Skittles. Wait 15 minutes then re-check glucose. If still low repeat this procedure. Once glucose is above 70 a snack containing carbohydrate and fat/protein should be provided, unless the next meal is within 30 minutes. If someone has a glucose above 70 but below 120 at bedtime or several hours before the next meal, they should be given a snack that contains carbohydrate and fat/protein. Review of Resident #1's medical record occurred on 02/01/24. Physician orders included: * 09/20/23, Novolog Flexpen U-100 Insulin [fast-acting insulin] . 100 unit/mL [milliliter] . 30 units; subcutaneous [under the skin] Once A Day 05:00 PM * 09/03/16, Tresiba FlexTouch U-100 [long-acting insulin] . 30 units; subcutaneous Special Instructions: HOLD FOR BS LESS THAN 150 At Bedtime 08:00 PM Resident #1's Medication Administration Record (MAR) for 01/13/24 showed the following: * 5:00 p.m., Novolog Insulin, 30 units administered by a nurse (#1) * 8:00 p.m., Blood Sugar Check, a nurse (#1) documented at 10:37 p.m., Administered late Comment: Administering care * 8:00 p.m., Tresiba Insulin, 30 units, a nurse (#1) documented two different entries at 10:37 p.m. Administered late Comment: Administering care and Site: Not Charted: On Hold Comment: bs 61 The medical record documentation showed a delay in completion of 8:00 p.m. orders. The nurses' notes stated the following: * 01/13/24 at 2:12 p.m. Emesis: Staff report resident had emesis of indigested food. Assisted with cleaning up. Will continue to monitor and have oncoming nurse assess. * 01/13/24 at 9:15 p.m. (created 01/15/24 06:56 a.m.) According to protocol, [resident's name] Tresiba was placed on hold because his Bs [BS] 83, which was less than the 150 the required amount to enable him to have one. In order to help bring his Bs up I gave him some cranberry juice, honey and cookie, which he ate a little, after lots of prompting. I came back after 30mins [sic] to recheck him and see if his Bs had improved, but instead his Bs has decreased further to 61. So I decided to tried [sic] again and gave him a little more juice, cookie and honey with the help of other staff members. After more prompting [resident name] was able to drink some of the juice, take the honey and eat some of cookie and he went to bed. Staff came to his room around 10:30 to changed [sic] and get him ready for bed. According to them he responded well. Around 11 [p.m.] he was heard hitting the wall and talking, which he does usually when he is in his room. When he was checked on the next time around 00: 15 [sic] [a.m.] he was found unresponsive and cold to touch and could not be revived. * 01/14/24 12:22 a.m. This writer entered resident's room and round [sic] resident expired. Body cold to touch. Yellow emesis and large amounts of clear phlegm found on bed next to mouth. Apical [specific point on the chest] HR [heart rate] absent for 1 minute, double verified by other charge nurse. During an interview on 02/01/24 at 3:49 p.m., an administrative staff member (#2) reported she called the certified nurse aide (CNA) (#3) on 02/01/24 to obtain her recollection of her interaction with Resident #1 on 01/13/2024 after 10:45 p.m. An administrative staff member (#2) reported the CNA (#3) confirmed she worked that night, arriving at 10:45 p.m. The CNA (#3) reported Resident #1 was not banging on the wall, but knocking, as he did all the time. He would play with his light and mess around. The nurse (#1) asked the CNA (#3) to bring the resident four ounces of cranberry juice and a whole packet of honey. The CNA (#3) gave Resident #1 the cranberry juice between 11:00 p.m. and 11:15 p.m. and it did not take the resident long to drink it. The CNA (#3) stated the resident coughed a little bit while drinking the cranberry juice. The CNA (#3) left the resident's head of the bed up because he looked comfortable and had closed his eyes. Resident #1's blood sugars included: 09/02/23 5:28 a.m. - 68 mg/dL - Failed to indicate what staff gave to the resident to increase blood sugar and re-check glucose after 15 minutes. 12/19/23 8:20 p.m. - 69 mg/dL - Failed to indicate what staff gave to the resident to increase blood sugar and re-check glucose after 15 minutes. 01/10/24 8:00 p.m. - 58 mg/dL, 8:20 p.m. - 80 mg/dL - Failed to indicate what staff gave to the resident to increase blood sugar. 01/11/24 7:37 p.m. - 78 mg/dL - Failed to indicate if snack was given at bedtime. 01/13/24 4:45 p.m. - 146 mg/dL - A nurse's note, dated 01/13/24 at 9:15 p.m., referenced blood sugars of 83 mg/dL and 61 mg/dL but failed to document the times staff obtained the blood sugars. During an interview on 02/01/24 at 2:40 p.m., two administrative staff members (#2 and #4) confirmed the following: * Staff are expected to follow the protocol [Blood Glucose - Protocol if Abnormal] unless there are other orders in place by the provider when a blood sugar is low. * Nurse (#1) had been the nurse on the 01/13/24 evening shift and hadn't charted the events from 01/13/24 so we requested documentation of a late entry on 01/15/24. * It is unknown what time the nurse obtained the blood glucoses of 83 mg/dL and 61 mg/dL. * The nurse should have rechecked the resident's blood sugar after he drank the juice following the BS of 61 mg/dL. * The record lacked documentation of an assessment following the resident's emesis on 01/13/24 at 2:12 p.m. * Staff were expected to offer Resident #1 a bedtime snack if his BS was less than 120 mg/dL. The record lacked evidence Resident #1 received a bedtime snack on 01/13/24. Facility staff failed to: * Re-check blood glucoses after 15 minutes when a blood glucose is below 70 mg/dL. * Document interventions for low blood glucoses or between 70 mg/dL and 120 mg/dL at bedtime. * Complete 01/13/24 8:00 p.m. orders in a timely manner. * Document the times the staff obtained blood sugars of 83 mg/dL and 61 mg/dL as referenced in a progress note dated 01/13/24 at 9:15 p.m. * Assess the resident following an emesis, as indicated in the progress note dated 01/13/24 at 2:12 p.m. * Create a progress note in a timely manner. The nurse created the 01/13/24 9:15 p.m. progress note over 33 hours later. * Provide an HS snack when blood sugars are between 70 mg/dL and 120 mg/dL at bedtime.