Health inspection·October 30, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A late entry Nursing progress note by the Registered Nurse Supervisor, Staff A, documented on 08/26/23 at 6:53 PM, Writer educated resident on hypoglycemic / hyperglycemic sign and symptoms (s/s). Writer had assigned nurse notify resident physician and family. Nursing teaching provided, Resident verbalized understanding. The Licensed Practical Nurse (LPN) assigned to the resident, Staff B, documented on 08/26/23 at 11:15 PM, Resident complained of (c/o) dizziness, frequent urination,and nausea. Glucose checked results 360, 8 units of Humalog given via sliding scale. Resident still c/o dizziness, and nausea. glucose checked again results 550. Doctor [name] notified via text. Instructed to give an additional 10 units of Humalog. Continued to monitor residents glucose every 30 min. Glucose decreased to 280 by 2030. Resident demanded another 10 units of insulin. I informed the resident that he has a routine dose of long acting insulin at bedtime. 2045: paramedics came up to the unit saying the resident in [room #] called 911. I was not aware of the resident calling 911. Went with EMS [Emergency Medical Services] to resident room. Resident stated 'I told her my blood sugar was high and she ignored me and she did nothing for me'. EMS checked resident's vitals and everything was in normal range. Resident was not transferred to hospital. Resident family notified. No distress noted at this time. Call light within reach. Further review of the Medication Administration Record (MAR) failed to document the blood sugars noted nor did the electronic record document the additional insulin dosage of Humalog 10 units prescribed by the physician. An interview was conducted on 10/30/23 at 3:41 PM with the Licensed Practical Nurse, Staff B. She did recall the incident noted above regarding the resident's elevated blood sugars. She recalled giving the initial 8 units which was documented. She stated she did not give the 10 units. The surveyor also informed the nurse the clinical record did not document the additional order prescribed for the resident for the elevated blood sugar of 550 [mg/dl] as noted in her progress note. She further stated the nursing supervisor was assisting her that evening and she thought she put the order in and carried out the order. The nurse stated we were really busy that night and she jotted down some notes in her personal notebook and proceeded to show the surveyor the handwritten notes she had. The surveyor again inquired about the resident receiving the 10 units of insulin. She confirmed she did not give the additional insulin coverage prescribed. She further showed the surveyor the text she stated she received from the Nursing Supervisor who texted the physician, which noted [Resident #1's] blood sugar at 4:00 PM was 360 [mg/dl] coverage of 8 units was given. We checked now because he complained of nausea and urination frequency and his accucheck was 550 [mg/dl]. I gave him 10 more units of the Humalog. Ok. Thank you. A telephone interview was conducted on 10/30/23 at approximately 4:30 PM with the Nursing Supervisor, Staff A, who reported she did recall the incident. When asked about giving the Resident #1 insulin, she stated she would not have given the additional unit unless she was on the medication cart, otherwise it would have been given by the nurse giving medications. The surveyor then relayed the text message, Staff B showed the surveyor regarding the text conversation she sent to the physician, which indicated she gave the resident Humalog 10 units for the accucheck of 550 [mg/dl]. She stated she does not recall giving the resident the 10 units but she too, will jot down personal notes because they were busy. She stated she wasn't home but she would check her notes when she got home and contact the surveyor. A telephone call was received on 10/30/23 at 6:35 PM from Staff A, who stated her notes indicate that she gave the Humalog 10 units. The surveyor requested that she email her the note. The note (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105911 If continuation sheet Page 2 of 3 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westgate Health and Rehabilitation Center 2300 Village Blvd West Palm Beach, FL 33409 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documented that Resident #1 complained of feeling nausea and frequent urination. Accucheck at 4:00 PM, 360 [mg/dl], coverage of 8 units given. Checked again at 5:56-6:00 PM, accucheck 550 [mg/dl], 10 more units of the Humalog given as ordered by the physician. It should be noted that Staff A took the time to write a late entry progress note about educating Resident #1 regarding the signs and symptoms of hypo/hyperglycemia and took the time to document personal notation of her alleged administration of said medication, but failed to document a telephone order from the physician and implementation of this order in the electronic clinical record. Event ID: Facility ID: 105911 If continuation sheet Page 3 of 3