Health inspection·April 7, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to perform a blood glucose check on a diabetic resident that was reporting symptoms of a low blood sugar for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. Residents Affected - Few The findings include: On 4/6/25 at 2:44 PM, R1 was seated in his wheelchair. R1 had bilateral above the knee amputations. R1 said he's had diabetes for a long time and knows when he feels off. R1 said usually his blood sugars run high, but on that morning (3/17/25) he felt weird. R1 described weird as feeling lightheaded and sweaty. R1 said he went to find the nurse and asked her to check his blood sugar because he thought it was low. R1 said the nurse (V9 - LPN) told him she was busy. R1 said he knew something was wrong, so he went to his room and called 911. R1 said he is a brittle diabetic meaning his blood sugar will be really high and then drop down really low. R1 said he didn't eat much dinner the night before and he thought that was why his blood sugar dropped. R1 said when the ambulance arrived, paramedics checked his blood sugar and it was 41 or 42. R1 said someone gave him a Glucerna to drink. R1 said the ambulance took him to the hospital and he was starting to feel better on the way. R1 stated, I think my blood sugar came up into the 80s when we were on the way to the hospital, the glucerna helped. R1 said he was at the hospital a few hours and came back to the facility. R1 said the facility checks his blood sugar 2-3 times a day and he didn't understand why V9 (LPN - Licensed Practical Nurse) wouldn't take it. R1's Facesheet dated 4/6/25 showed he had diagnoses to include, but not limited to: epileptic seizures, lack of coordination, bilateral BKA (below the knee amputations), weakness, and diabetes. R1's facility assessment dated [DATE] showed he was cognitively intact R1's Physician Order Sheet (POS) dated 4/6/25 showed he had orders for blood sugar monitoring as needed and the doctor should be called if the blood sugar is less than 70 or greater than 400. R1's POS showed he had an order for Glucagon Emergency Kit 1 mg if his blood sugar was less than 60 and he was unable to swallow. R1's POS also showed that he was on scheduled long and short-acting insulin. R1's Blood Glucose Summary showed his blood sugar was 380 on 3/16/25 at 5:18 PM. The next blood sugar documented was on 3/17/25 at 4:29 PM. There was no documented blood sugar on or near 5 AM on 3/17/25. R1's Progress Note dated 3/17/25 showed at 5:00 AM, R1 approached V9 (LPN) and requested she check his blood sugar. This note showed V9 said she was finishing with another resident and R1 became Page 1 of 3 145850 145850 04/07/2025 City View Multicare Center 5825 West Cermak Road Cicero, IL 60804

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few upset. This note showed R1 went to his room and called 911 with his cell phone. This note showed the paramedics arrived as V9 was going to R1's room to assess him. At 5:20 AM, R1 refused to allow blood sugar check and resident was transferred to the hospital via ambulance. At 10:27 AM, R1 returned to the facility. On 4/6/25 at 10:59 AM, V7 (Nurse Supervisor) said he was working as the night shift supervisor on 3/17/25. V7 said he wasn't on R1's floor when the issue started. V7 said he was surprised to see the ambulance because none of the nurses' had notified him that 911 was being called. I asked the front desk person why the ambulance was here and they told me that someone on R1's floor called 911. V7 said that's when he went up there. V7 said V9 (LPN) was R1's nurse. V7 said when he arrived to the floor, R1 was there and the nurse and paramedics were talking. V7 said R1 looked okay. V7 said he's worked with R1 before and he knows that he is diabetic. V7 said the paramedics took the blood sugar and it was low. V7 said he didn't recall the exact number, but it was in the 40s. V7 said he gave R1 a Glucerna to drink and tried to explain to the paramedics that the facility could provide care for R1. V7 said the paramedics said the nurse refused to check R1's blood sugar. V7 stated, I wasn't there for that part. The nurse told me that she was with another resident. V7 said R1's blood sugar is usually high, but it does fluctuate. V7 said there were two functioning blood glucose monitors available on the floor. V7 said R1 was able to make his needs know and could describe how he was feeling. V7 said R1 would be able to tell if he was hypoglycemic. On 4/6/25 at 11:29 AM, V12 (Firefighter/Paramedic) said they responded to a call at the facility for diabetic problems. V12 stated, When we arrived on the floor, the staff appeared confused. Then a [V9 - LPN] realized [R1] had called 911 from his own phone. While we were talking to the nurse the resident wheeled around the corner. [R1] told us he felt like he his blood sugar was low and he wanted a (sugary drink). V12 said the V9 said R1 was fine. V12 said he asked V9 what R1's blood sugar was. V12 said she told him that she didn't check his blood sugar and she didn't have an order to do so. V12 said V9 was rude to the paramedics and argumentative. V12 said R1 was showing signs of hypoglycemia (complained of lightheadedness, feeling dizzy, and he was pale and sweaty). V12 said he checked R1's blood sugar and it was 42. V12 said that is dangerously low and R1 could have suffered serious consequences if his blood sugar was properly treated. V12 said the facility provided R1 with a drink and R1 was taken to the hospital for evaluation. V12 said R1's blood sugar was checked in route to the hospital. V12 said R1's blood sugar improved and R1 reported feeling better. V12 said the call was early in the morning, but he was not sure on the exact time. On 4/7/25 at 12:22 PM, V11 (LPN) said she was working 3/17/25, but she was not assigned to R1. V11 said she missed the beginning of the interaction. V11 said she became aware when the paramedics arrived. V11 said she was surprised to see the paramedics. V11 said R1 called them from his personal phone. V11 said V9 was the nurse and she was arguing with the paramedics. V11 said V9 was trying to tell the paramedics that R1 appeared fine. V11 said the paramedics asked V9 if she checked R1's blood sugar and she said no. V11 stated, At that point, I just wanted to check R1's blood sugar. V11 said the paramedics took R1's blood sugar and it was low. V11 said R1's blood sugar was concerning and he needed to be provided some sugar and more monitoring. V11 said some signs and symptoms of hypoglycemia (low blood sugar) include pale skin, sweating, confusion, and possible loss of consciousness. V11 said R1 knows his body. V11 said, If he asked for his blood sugar to be checked, then she should have checked it. V11 said she wasn't aware if the facility had standing orders for treatment of hypoglycemia, but if R1 was alert and able to swallow, she would give him juice and recheck his blood sugar. V11 said if he couldn't swallow, then we have an emergency sugar medication we can give. On 4/7/25 at 2:49 PM, V2 (DON - Director of Nursing) said R1 was alert and oriented and could make 145850 Page 2 of 3 145850 04/07/2025 City View Multicare Center 5825 West Cermak Road Cicero, IL 60804

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his needs know. V2 said R1 knows his body and would be able to tell the nurse if he thought his blood sugar was low. V2 said there are glucometers available and if a resident is complaining about a low blood sugar, then the nurse should check the blood sugar. V2 said R1 can become angry and impulsive when his needs are not met immediately. V2 said it's possible the nurse was providing care to someone else, but when they are finished they should make checking the blood sugar a priority. V2 said she was not aware of a reason a nurse should refuse to check a resident's blood sugar. V2 said R1 is noncompliant with diabetic diets and occasionally refuses blood sugar checks. V2 said R1 normally runs high, but 42 is dangerously low. V2 stated, I'm sure he felt bad, if it dropped that much. A policy for Management of Diabetic Residents was requested and not received. V1 (Administrator) said the closest policy they have was Following Physician's Orders. 145850 Page 3 of 3