Health inspection·December 4, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of information from Medscape, the facility failed to ensure the physician was notified regarding a residents low blood glucose reading. This affected one (#14) of three residents reviewed for notification of change. The facility census was 45. Findings include: Review of medical record for Resident #14 revealed admission date of 08/17/23. Diagnoses included acute kidney failure, sepsis, type two diabetes mellitus with hyperglycemia, and bipolar disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and he required moderate assistance with eating, maximum assistance for bed mobility and dependence for transfers. Review of the physician orders for Resident #14 revealed an order for Lantus (long-acting insulin) 20 units subcutaneously two times daily. Hold medication for a blood sugar of less then 80 and contact physician for further instructions. This was scheduled for 8:00 A.M. and 8:00 P.M. with a start date of 12/12/23. Review of Resident #14's Electronic Medication Administration Record (EMAR) note revealed on 12/20/23 at 5:00 A.M. the residents blood glucose was 48, and his Lantus was held. There was no documentation that Resident #14's physician was notified of the low blood sugar reading. Interview on 12/28/23 at 11:44 A.M. with Licensed Practical Nurse (LPN) #102 revealed when he checked the blood glucose of Resident #14 around 6:00 A.M. on 12/20/23 it was 48. LPN #102 confirmed Resident #14 did not have an order for glucose monitoring at 6:00 A.M. and that the residents blood sugar was checked out of habit as the resident previously had an order to check it at 6:00 A.M. but it was changed to 8:00 A.M. LPN #102 stated Resident #14 was alert, oriented and was given apple juice on 12/20/23 at 6:00 A.M. A recheck about ten minutes later revealed a blood glucose of 90. LPN #102 verified he did not contact the physician as ordered. LPN #102 also confirmed the assessment, monitoring and/or intervention provided to Resident #14 for the low blood sugar reading of 48 was not documented. Review of information from Medscape at https://emedicine.medscape.com/article/2087913-overview?form=fpf revealed the normal glucose levels for an adult are between 74-106 milligrams (mg) per(/) deciliter (dl) with possible critical values for an adult male as less than 50 mg/dl. Page 1 of 8 365566 365566 12/04/2023 Carecore at Minster 24 North Hamilton Street Minster, OH 45865

F 0580 This is a new deficiency based on the post survey revisit for the complaint survey completed on 12/04/23. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365566 Page 2 of 8 365566 12/04/2023 Carecore at Minster 24 North Hamilton Street Minster, OH 45865

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, and staff and Physician #850 interviews, the facility failed to ensure a newly admitted resident received appropriate diabetes care when the facility staff failed to clarify a resident's diabetes diagnosis and the need for blood sugar monitoring and insulin administration. This resulted in Actual Harm when staff failed to monitor Resident #04's blood sugars and the resident subsequently had a change in condition resulting in hospitalization and a diagnosis of hyperglycemia requiring intravenous (IV) and subcutaneous (SQ) insulin administration and (IV) fluids. Additionally, the facility failed to have blood glucose monitoring and insulin in place for Resident #38, which placed the resident at risk for more than minimal harm. This affected two (Residents #04 and #38) of three residents reviewed for diabetes management. The facility census was 50. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #04 revealed an admission date of 08/17/23. Diagnoses included type two diabetes mellitus with hyperglycemia (11/02/23), encephalopathy, bipolar disorder, impulse disorder, and transient ischemic attack and cerebral infarction without residual deficits. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was cognitively impaired and was dependent on staff for all aspects of daily living. The assessment identified a diagnosis of diabetes mellitus. The assessment did not indicate the use of insulin. Review of the paperwork from the sending facility (Long-Term Care Acute Hospital [LTACH]) revealed Resident #04 had a diagnosis of diabetes. The documents revealed discharge medications of acetaminophen 650 milligrams (mg) by mouth every six hours as needed for fever greater than 100.4 degrees Fahrenheit and all levels of pain. Review of the LTACH Patient Care Summary dated 08/06/23 revealed Resident #04 had a history of diabetes with insulin use. Review of the laboratory results revealed on 08/25/23, 08/28/23, 10/06/23, and 11/03/23 Resident #04 refused laboratory (lab) draws. Review of Resident #04's admission orders dated 08/17/23 revealed the only medication ordered was acetaminophen 650 mg orally every six hours as needed for pain. Further review of physician orders from August 2023 to October 2023 revealed no orders for blood sugar monitoring or insulin. Further review of the medical record revealed no documentation the physician was notified of Resident #04 having diabetes and/or clarification regarding the need for blood sugar monitoring or insulin administration. Review of the hospital records dated 10/30/23 revealed Resident #04 presented to the emergency department for lethargy that began that morning. The note indicated Resident #04 was started on an antibiotic on 10/29/23 for symptoms of a Urinary Tract Infection (UTI) and was his usual self until this morning when found lethargic and less responsive. Laboratory tests revealed a blood glucose level of greater than 1,000 milligrams per deciliter (mg/dL). Per staff at the nursing home, Resident #04 had not been receiving treatment for diabetes as they said he had no history of diabetes. The assessment revealed diagnoses of sepsis, acute kidney injury, acute UTI, and hyperglycemia. The note 365566 Page 3 of 8 365566 12/04/2023 Carecore at Minster 24 North Hamilton Street Minster, OH 45865

F 0684 Level of Harm - Actual harm Residents Affected - Few indicated Resident #04 was not in DKA (diabetic ketoacidosis). Resident #04 received IV insulin and SQ insulin in the emergency room and will start a sliding scale insulin and a long-acting insulin. Upon return to the nursing facility will continue with sliding scale and long-acting insulin. Interview on 12/04/23 at 2:52 P.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #04 did not have an order for blood sugar monitoring or insulin from his admission on [DATE] until he was hospitalized on [DATE]. LPN #100 stated when a resident admits with a diagnosis of diabetes mellitus with no order for blood sugar monitoring, the doctor should be contacted to obtain an order for blood sugar monitoring, at a minimum. Interview on 12/04/23 at 3:05 P.M. with Clinical Director of Operations (CDO) #800 revealed Resident #04 had been on insulin at the hospital, but the discharge orders lacked documentation for insulin or blood sugar monitoring. The list of diagnoses included diabetes mellitus type II. It would be assumed nurses would clarify if a diagnosis of diabetes was found. CDO #800 confirmed prior to Resident #04's admission to the facility he had a history of being diabetic and required insulin administration. CDO #880 further verified Resident #04 was hospitalized due to being hyperglycemic and required insulin administration on a regular basis when the resident returned from the hospital. Interview on 12/04/23 at 3:27 P.M. with LPN #102 revealed when a diagnosis of diabetes is noted in the medical record with no order for blood sugar monitoring or insulin, the doctor should be notified to clarify. Interview on 12/04/23 at 3:32 P.M. with LPN #103 revealed the doctor or an assistant should be notified when a resident admits with a diagnosis of diabetes without any blood sugar monitoring or insulin. Interview on 12/04/23 at 4:47 P.M. with CDO #800 revealed the facility is to follow the admission Review checklist upon admissions. The checklist indicated physician orders will be clarified with a doctor or nurse practitioner within one hour and all medications will be clarified, and any concerns clarified. A baseline care plan will then be completed. Interview on 12/04/23 at 4:55 P.M. with Physician #850 confirmed the lack of diabetes care upon Resident #04's admission was a miscommunication issue. Physician #850 stated going forward, all residents with a history of diabetes will receive a minimum of blood glucose checks daily. 2. Review of the medical record of Resident #38 revealed an admission date of 09/28/23. Diagnoses include vascular dementia, unspecified mood disorder, and diabetes mellitus type II. Review of the admission MDS assessment dated [DATE] revealed Resident #38 was cognitively impaired and required supervision with bed mobility, transfers, and personal hygiene. The assessment further indicated the use of antipsychotic medication but no insulin. Review of physician orders revealed no insulin ordered at the facility. Review of the discharge paperwork from the hospital revealed Resident #38 had been receiving insulin Human Lispro per sliding scale while at the hospital; however, the discharge orders revealed no documentation for insulin, either discontinued, changed, or continued. Review of the medical record revealed blood glucose results dated 10/09/23 at 6:28 A.M. to read 90 365566 Page 4 of 8 365566 12/04/2023 Carecore at Minster 24 North Hamilton Street Minster, OH 45865

F 0684 Level of Harm - Actual harm Residents Affected - Few mg/dL (low), 10/23/23 at 6:04 A.M. to read as 102 mg/dL (low), and 12/04/23 at 7:03 A.M. revealed a blood glucose of 108 mg/dL (low). Hemoglobin A1C (blood sugar test) drawn on 12/04/23 was 6.2% with normal range of 4.1 to 6.1%. Interview on 12/04/23 at 3:27 P.M. with LPN #102 revealed when a diagnosis of diabetes is noted in the medical record, but no order for blood sugar monitoring or insulin, the doctor should be notified to clarify. LPN #102 verified Resident #38 had blood glucose monitoring and no insulin ordered. Interview on 12/04/23 at 3:35 P.M. with CDO #800 revealed Resident #38's current blood sugar read 288 mg/dL after having recently drank a large glass of cranberry juice. CDO #800 stated the physician would be notified of the lack of blood glucose monitoring and would obtain an order. The facility did not provide a policy related to diabetic care. This deficiency represents non-compliance investigated under Complaint Number OH00148261. 365566 Page 5 of 8 365566 12/04/2023 Carecore at Minster 24 North Hamilton Street Minster, OH 45865

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review and staff interviews, the facility failed to ensure a residents admission physician orders were implemented. This affected one (#11) of three residents reviewed. The facility census was 45. Residents Affected - Few Findings include: Review of medical record for Resident #11 revealed admission date of 12/22/23. Medical diagnoses included dementia without behaviors, chronic pain, non-pressure chronic ulcer, and atrial fibrillation. Review of the transfer admission orders for Resident #11 revealed an order for Milk of Magnesia (laxative) 30 milliliters (ml) every 24 hours as needed. Further review of the physician orders and December 2023 Medication Administration Record (MAR) for Resident #11 revealed no order for Milk of Magnesia. Interview on 12/27/23 at 10:54 A.M. with the Director of Nursing (DON) verified an admission order for Milk of Magnesia 30 ml every 24 hours as needed for Resident #11 was not ordered and not placed on the MAR upon the residents admission. This is a new deficiency based on the post survey revisit for the complaint survey completed on 12/04/23. 365566 Page 6 of 8 365566 12/04/2023 Carecore at Minster 24 North Hamilton Street Minster, OH 45865

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of information from Medscape, the facility failed to ensure insulin was administered as ordered resulting in significant medication errors. This affected one (#14) of three residents reviewed for blood glucose monitoring. The facility census was 45. Findings include: Review of medical record for Resident #14 revealed admission date of 08/17/23. Diagnoses included acute kidney failure, sepsis, type two diabetes mellitus with hyperglycemia, and bipolar disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and he required moderate assistance with eating, maximum assistance for bed mobility and dependence for transfers. Review of the physician orders for Resident #14 revealed an order for Lantus (long-acting insulin) 20 units subcutaneously two times daily. Hold medication for a blood sugar of less then 80 and contact physician for further instructions. This was scheduled for 8:00 A.M. and 8:00 P.M. with a start date of 12/12/23. Review of Resident #14's December 2023 Medication Administration Record (MAR) revealed an the order for the 8:00 A.M. and 8:00 P.M. Lantus order had two boxes for each time slot, one for the blood sugar result, and the second for signature the medication was given. There was no record of the blood sugar monitoring until 12/20/23. Further record review of the December 2023 MAR revealed on 12/20/23 and again on 12/22/23 the 8:00 A.M. Lantus dose was coded as a nine indicating a coinciding nursing note. Review of Resident #14's Electronic Medication Administration Record (EMAR) note revealed on 12/20/23 at 5:00 A.M. the residents blood glucose was 48, and his Lantus was held. There was no documentation that Resident #14's physician was notified of the low blood sugar reading. Additionally, there was no documentation of what care was provided for Resident #14's blood sugar reading of 48 other than holding holding the Lantus. Review of Resident #14's EMAR note dated 12/22/23 at 8:00 A.M. revealed the residents Lantus insulin was not administered as ordered due to a blood sugar of 94. Interview on 12/28/23 at 10:33 A.M. with the Director of Nursing (DON) revealed the accuchecks for Resident #14 were ordered twice daily. Upon a review it was discovered the accucheck times of 8:00 A.M. and 4:00 P.M. did not coincide with his Lantus order times of 8:00 A.M. and 8:00 P.M., so the original accucheck order was discontinued. The DON verified this change was needed to ensure the accuchecks were completed at 8:00 A.M. and 8:00 P.M. so ordered parameters to hold Lantus of glucose was under 80 were followed. Interview on 12/28/23 at 11:34 A.M. with Licensed Practical Nurse (LPN) #100 verified she held the Lantus for Resident #14 on 12/22/23 for a blood glucose of 94 in error. LPN #100 stated she misread 365566 Page 7 of 8 365566 12/04/2023 Carecore at Minster 24 North Hamilton Street Minster, OH 45865

F 0761 the parameters and the Lantus should have been given. Level of Harm - Minimal harm or potential for actual harm Interview on 12/28/23 at 11:44 A.M. with LPN #102 revealed when he checked the blood glucose of Resident #14 around 6:00 A.M. on 12/20/23 it was 48. LPN #102 confirmed Resident #14 did not have an order for glucose monitoring at 6:00 A.M. and that the residents blood sugar was checked out of habit as the resident previously had an order to check it at 6:00 A.M. but it was changed to 8:00 A.M. LPN #102 stated Resident #14 was alert, oriented and was given apple juice on 12/20/23 at 6:00 A.M. A recheck about ten minutes later revealed a blood glucose of 90. LPN #102 verified he did not contact the physician as ordered. LPN #102 also confirmed the care provided to Resident #14 for the low blood sugar reading of 48 was not documented. Residents Affected - Few Interview on 12/28/23 at 12:19 P.M. with LPN #103 revealed on 12/20/23 she received in report Resident #14's blood glucose had been 48 prior to the start of her shift on 12/20/23 at 7:00 A.M. LPN #103 shared she did recheck Resident #14's blood glucose around 8:00 A.M. as ordered and it was 198. LPN #103 stated she did not feel comfortable giving the medication (Lantus) because Resident #14's glucose had been running low in the morning. LPN #103 did confirm Lantus was a long-acting insulin. LPN #103 alleged she did contact the physician on 12/20/23 for further instructions but nothing was documented. Review of information from Medscape at https://emedicine.medscape.com/article/2087913-overview?form=fpf revealed the normal glucose levels for an adult are between 74-106 milligrams (mg) per(/) deciliter (dl) with possible critical values for an adult male as less than 50 mg/dl. This is a new deficiency based on the post survey revisit for the complaint survey completed on 12/04/23. 365566 Page 8 of 8