Health inspection·April 4, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one (R2) of three residents reviewed for quality of care received appropriate care and management for the diagnosis of diabetes, by failing to monitor R2's blood sugar levels upon admission and failing to provide continuity of care through medication administration in a total sample of six residents. Residents Affected - Few Findings include: According to R2 face sheet, R2 admission date is 2/11/2025. R2 has diagnoses that include but are not limited to type 2 diabetes mellitus; acute and chronic respiratory failure with hypoxia and hypercapnia; chronic obstructive pulmonary disease; heart failure; chronic kidney disease, stage 4. R2 care plan reads in part: Resident has the potential for hypo/hyperglycemic reactions secondary to diagnosis of diabetes mellitus, initiated 2/12/2025. 4/3/25, at 1:32 PM, V6 (Licensed Practical Nurse) stated for blood sugar checks, we go by the MAR (medication administration record), what the doctors order. They are usually taken before meals. We do have some residents that get checks four times daily because they get Lantus insulin (A slow acting insulin that is usually given on the night/evening shift). If a resident is on an insulin they should be getting blood sugar checks. You have to monitor the blood glucose level. You have to know what the blood sugar level is in order to give the insulin. Diabetics that are on oral medications do get blood sugar checks but maybe not as often as if they were on insulin. Its according to what the doctor orders. Blood sugar monitoring is dependent on what the doctor orders. 4/3/25, at 2:49 PM, V8 (Licensed Practical Nurse) stated blood sugar checks are done per the physician order. All diabetic residents should be getting blood sugar checks. You have to know where their sugar level is before giving insulin. If the sugar is low, interventions need to be implemented and notify the physician. If blood sugar level is too high the physician needs to be notified. For a diabetic resident you check the blood sugar before giving insulin. You need to check if the resident is on oral medications as well. You need to know the parameters. When the resident is admitted , if the resident is a diabetic, and if there is an order for insulin, the physician should be contacted immediately upon admission for blood sugar check and insulin administration. It is not proper for a diabetic resident not to have blood sugar checks, or not be given medications for a week after admission. If not checking the blood sugar level and still administering insulin their sugar can drop, and the resident could end up in a diabetic coma. You need to know if the blood sugar level is too high because you need to notify the physician if it is. 4/3/25, at 4:18 PM, V4 (Assistant Director of Nursing) stated the expectation is to follow doctors' orders for blood sugar checks. All the diabetics get blood sugar checks, at different frequencies. Page 1 of 3 145429 145429 04/04/2025 Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few If the resident is receiving insulin, they should be getting blood sugar checks to monitor for levels too low or too high. If the blood sugar level is too low the resident could become dizzy and pass out. It is a dangerous thing. If the level is too high could go into diabetic ketoacidosis. We follow the orders from the hospital. We reconcile with the doctor. The nurse would know to add the blood sugar check order inside the order for the short acting insulin. For the long-acting insulin, the nurse goes by the hospital record for the blood sugar check. R2 is on Lantus and Trulicity. Since she is diabetic and on insulin the blood sugar check would be a standing order, in the morning and at bedtime. I would discuss blood sugar check frequency with the doctor. 4/3/25, at 5:23 PM, V3 (Director of Nursing) stated for newly admitted diabetics and all residents, we should be following doctors' orders for blood glucose monitoring and medication administration. R2 should have been receiving blood glucose monitoring from admission through 2/18/25, because R2 is a diabetic and receiving insulin. R2 should have been receiving blood glucose monitoring to monitor blood sugar levels. We monitor levels to know how to administer insulin. If insulin is administered incorrectly there could potentially be an adverse effect/reaction. R2 was discharged from the hospital on insulin. There should be blood sugar monitoring for long acting and short acting insulins and oral medications. R2 should have been receiving whatever medications were ordered. Insulin was ordered, it did not come from pharmacy. It was discontinued and a different insulin was ordered and started on 2/15/25. The blood sugar monitoring was not documented from 2/12/25 to 2/18/25. R2 hospital discharge medication list indicates R2 was discharged taking: empagliflozin 10 MG in the morning; Semglee insulin glargine 15 units daily; Trulicity 0.75 MG/0.5ML weekly. R2 Census List indicates R2 has been active status in the facility since 2/11/2025 6:35 PM. R2 Weights and Vitals Summary indicates one blood sugar reading on 2/11/2025, with result of 360. No other blood sugar readings noted until 2/18/2025 with result of 214. According to R2 physician order summary, orders for diabetes mellitus include: -Blood Glucose monitoring: call physician for results less than 50 or greater than 400, start date 2/18/2025, no end date. -Semglee Insulin Glargine, 15 unit subcutaneous in the morning, start date 2/12/2025, end date 3/12/2025. -Lantus Insulin Glargine, 15 unit subcutaneous at bedtime, start date 2/15/2025, end date 3/12/2025. -Empagliflozin tablet 10 MG in the morning, start date 2/12/2025, no end date. -Trulicity 0.75 MG/0.5 ML subcutaneous every Monday, start date 2/17/2025, no end date. R2 medication admission record, 2/1/25-2/28/25, indicates blood glucose monitoring started 2/18/25 with result of 214. R2 medication admission record, 2/1/25-2/28/25, indicates R2 was administered diabetes medication, Empagliflozin, 2/14 through 2/17. Blood glucose monitoring was not started until 2/18/25. 145429 Page 2 of 3 145429 04/04/2025 Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621

F 0684 Level of Harm - Minimal harm or potential for actual harm R2 medication admission record, 2/1/25-2/28/25, indicates R2 was administered diabetes medication, Lantus Insulin Glargine, 2/15 through 2/17. Blood glucose monitoring was not started until 2/18/25. R2 medication admission record, 2/1/25-2/28/25, indicates R2 was administered diabetes medication, Trulicity, 2/17. Blood glucose monitoring was not started until 2/18/25. Residents Affected - Few R2 medication admission record, 2/1/25-2/28/25, indicates R2 had an order for diabetes medication, Semglee Insulin Glargine, that was not administered. Progress note 2/15/2025 indicates, awaiting supply from pharmacy. Mayo Clinic at https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/blood-sugar/art-20046628#:~:text=If%20you%20take%20 documents in part: Blood sugar testing is an important part of diabetes care. If you have diabetes, testing your blood sugar levels can be a key part of staying healthy. Blood sugar testing helps many people with diabetes manage the condition and prevent health problems. If you take insulin to manage type 2 diabetes, your healthcare professional might recommend a CGM (continuous glucose monitors). Or you may need blood sugar testing several times a day. The exact number of times depends on the type and amount of insulin you use. Often, testing is advised before meals and at bedtime if you take more than one shot of insulin a day. You may need to test only before breakfast and sometimes before dinner or at bedtime if you use an intermediate- or a long-acting insulin. Facility policy Assure Platinum Blood Glucose Monitoring, 8/2024, documents in part: Document test results in medical record. 145429 Page 3 of 3