Health inspection·November 5, 2025

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 closed medical record review, hospital record review, staff interview and policy review, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #88. The facility failed to ensure changes in the resident's medical condition were comprehensively assessed, that high blood glucose levels were communicated to the medical provider, and individualized interventions were implemented. This resulted in Actual Harm with subsequent hospitalization when on 06/23/25 Resident #88 had a high blood glucose reading of 471 milligrams per deciliter (mg/dL) (normal ranges from 80 to 130 mg/dL in adults with type two diabetes) requiring notification to a medical provider, which was not completed. On 06/26/25 and 06/27/25, Resident #88 presented with symptoms of hyperglycemia with changes in mental status, drowsiness, incontinence, and dietary changes. Certified Nursing Assistant (CNA) #127 and CNA #135 reported the changes to nursing staff. Certified Nurse Practitioner (CNP) #200 was informed of the blood glucose reading high (indicating a reading over 500 mg/dL) on 06/27/25 after lunch and the staff began to treat the residents blood sugar with insulin. On 06/27/25 the resident was sent to the hospital and diagnosed with diabetic ketoacidosis (DKA) (a life threatening complication of diabetes that occurs when the body does not have enough insulin), acute metabolic encephalopathy and acute kidney injury, in addition to a blood glucose reading of 1157 mg/dL. This affected one (Resident #88) of three residents reviewed for changes in condition. The facility census was 87. Findings include:Review of the medical record for Resident #88 revealed an admission date of 07/31/24 and a discharge date of 06/27/25. Diagnoses included heart disease, heart failure, muscle weakness, cognitive communication deficit, muscle wasting, hemiplegia and hemiparesis, vascular disease and type two diabetes. Review of the physician orders revealed an order dated 08/01/24 to monitor for signs and symptoms of hypo/hyper glycemia (sweating, tremor, pallor, tachycardia, palpitations, nervousness, headaches, confusion, light headedness, slurred speech, lack of concentration, irritability, and staggering gait). Review of the physician orders revealed an order dated 08/05/24 for a blood glucose check (accu-check) in the morning once weekly on Mondays for hypo/hyperglycemia monitoring. The instructions on the order were to notify the physician if the blood sugar was under 60 or over 400 mg/dL. Review of the plan of care dated 08/05/24 revealed Resident #88 had diabetes mellitus with interventions to administer medications per medical provider orders, observe for side effects and effectiveness and report abnormal findings, observe for signs and symptoms of hyperglycemia (increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep, rapid and labored breathing), stupor and coma) and report findings to the medical provider, report findings of hypoglycemia (sweating, tremors, increased heart rate, confusion, blurred speech, lack of coordination) to medical provider, obtain and monitor laboratory (lab) results and diagnostic studies, obtain blood sugars according to physician orders, and offer snack and provide diet as ordered. Review of Residents Affected - Few Page 1 of 6 365686 365686 11/05/2025 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0684 Level of Harm - Actual harm Residents Affected - Few Resident #88's physician orders revealed an order dated 10/22/24 for Farxiga oral tablet 10 milligrams (mg) with instructions to administer one tablet by mouth once daily for diabetes. There were no standing insulin orders. Review of the lab results dated 02/27/25 revealed Resident #88 had a blood glucose of 159 mg/dL with a reference range for non-fasting of 65-125 mg/dL and a hemoglobin A1C (a blood test that shows an average levels of blood sugar levels over a two to three month period) of 6.5 percent (with a reference range of 4.1-6.1 percent) and a mean glucose of 140 mg/dL (with a reference range of 70-120 mg/dL). Review of Resident #88's blood sugar checks from 03/03/25 to 06/16/25 revealed results from 122 to 300 mg/dL with five readings in the 100's, ten readings in the 200's and one at 300 with results trending up over the last six months. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 had intact cognition and was independent with activities of daily living (ADL). Resident #88 only required supervision/touching assistance with ambulation and bathing. The MDS assessment stated the resident was always continent of bowel and bladder and received a hypoglycemic medication but was not receiving insulin injections. Review of the lab results dated 05/27/25 revealed Resident #88 had a blood glucose of 214 mg/dL, a hemoglobin A1C of 7.9 percent, and a mean glucose of 180 mg/dL. Review of the progress note dated 05/28/25 revealed Certified Nurse Practitioner (CNP) #200 reported Resident #88 had elevated blood glucose from 120 to 300 mg/dL with a plan to add Glipizide 5 mg daily and to continue the Farxiga. The note included an addendum of further discussion with the resident and pharmacist and it was thought the increased Hemoglobin A1C from 6.5 to 7.9 percent was related to the resident's diet. CNP #200 reported a discussion with the resident who was agreeable to managing his diet instead of making medication changes. Review of the blood sugar checks on 06/23/25 revealed Resident #88 had result of 471 mg/dL. Review of the progress note date 06/23/25 revealed Resident #88 had a blood sugar result of 373 mg/dL. Review of Resident #88's progress note dated 06/27/25 at 3:41 P.M. revealed the resident was seen by CNP #200 for hyperglycemia with blood sugars reading high (over 500). The note stated per staff report, the resident had not been acting right since lunch. The bedside nurse took vital signs which were reported within normal limits, then CNP #200 instructed the registered nurse to take a blood sugar reading which resulted as high. The note stated the resident was not on insulin injections and was allergic to Metformin, only receiving Farxiga. The resident was given two units of Lispro and was re-checked 30 minutes later with the glucometer still reading high. CNP #200 instructed the bedside nurse to give an additional two units of Lispro with a plan for recheck. CNP #200 also mentioned adding a sliding scale for insulin with meals. The plan was for labs to be drawn on Monday, 06/30/25. The note revealed upon assessment, the resident had sluggish responses and was less verbal than usual. Review of Resident #88's progress note dated 06/27/25 at 3:48 P.M. revealed the nurse found the resident lethargic with slow speech, and he was not acting his normal self. He only ate 50 percent of breakfast and lunch and was able to drink all fluids. The nurse notified CNP #200 of the change in condition and vitals were taken and were within normal limits and a blood sugar was taken and read high. A new order for Lispro two units was obtained. Review of Resident #88's physician orders revealed an order dated 06/27/25 for insulin Lispro (rapid acting insulin) with instructions to inject two units (u) one time only for diabetes mellitus. This medication was ordered at 2:00 P.M. and documented as administered at 2:00 P.M. Review of Resident #88's physician orders revealed an order dated 06/27/25 for insulin Lispro with instructions to inject two units one time only for diabetes mellitus. This medication was ordered at 3:00 P.M. and documented as administered at 4:05 P.M. Review of Resident #88's progress note dated 06/27/25 at 4:43 P.M. from the on-call CNP #250 revealed the resident had a telehealth visit for blood sugar readings high. The resident had already received two units twice of 365686 Page 2 of 6 365686 11/05/2025 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0684 Level of Harm - Actual harm Residents Affected - Few insulin Lispro so far with no improvement in blood sugar readings. The note revealed the resident was symptomatic with fatigue and seen by facility provider and sliding scale coverage was ordered with a plan to recheck the blood sugar in two hours and report to the on-call provider if it was still elevated at 6:30 P.M. Review of Resident #88's progress note dated 06/27/25 at 4:51 P.M. revealed the nurse administered another one-time order for insulin Lispro two units. Later, the nurse checked the blood sugar and it had still read high. The nurse called the CNP #200 who instructed to keep the sliding scale order and recheck in two hours. Review of the physician orders revealed an order dated 06/27/25 for insulin Lispro sliding scale with instructions stating if blood sugar was from 150-200 mg/dL give 2 units; 201-250 mg/dL give 4 units; 251-300 mg/dL give 6 units; 301-350 mg/dL give 8 units; and if over 350 mg/dL give 8 units and recheck in one hour, if it remains over 350 call the physician or nurse practitioner. Lispro was ordered at 8:00 A.M., 12:00 P.M. and 5:00 P.M. and documented as administered within the 5:00 P.M. time slot. Review of progress note dated 06/27/25 at 6:20 P.M. revealed the on call CNP #250 ordered staff to administer eight units of insulin and call her back after two hours which was 6:30 P.M. The resident's' family arrived at the facility and 911 was contacted and the resident was transferred to the hospital. The note also stated a blood sugar reading of 404 mg/dL was taken just prior to the transfer to the hospital. Review of the hospital emergency room notes dated 06/27/25 revealed Resident #88 presented with altered mental status and reported high blood glucose readings of high. The note stated the resident was drowsy, but alert and made eye movements but was not speaking and movements were slow, and he did not follow commands upon arrival. Resident #88 was found to have diabetic ketoacidosis (DKA) (a life threatening complication of diabetes that occurs when the body does not have enough insulin) and acute renal failure and he would be admitted . Basic labs were completed at 8:08 P.M. with a recheck at 9:58 P.M. after treatment had been initiated for DKA. Initial lab results included a sodium of 132 milliequivalents per liter (mEq/L) (normal ranges from around 135-145 mEq/L), potassium of 6.2 millimoles per liter (mmol/L) (normal ranges from around 3.6 to 5.2 mmol/L), chloride of 97 mEq/L (normal ranges from around 96 to 106 mEq/L), glucose of 1157 mg/dL, blood urea nitrogen (BUN) of 112 mg/dL (normal ranges from around 8-24 mg/dL), and creatinine of 2.29 mg/dL (normal ranges from 0.7-1.3 mg/dL) with repeat labs showing sodium of 146 mEq/L, potassium of 5.4 mmol/L, chloride of 112 mEq/L, glucose of 799 mg/dL, BUN of 107 mg/dL, and creatinine of 2.39 mg/dL. Both glucose lab results were critical. Review of the hospital history and physical dated 06/28/25 at 12:12 A.M. revealed Resident #88 had DKA with type two diabetes with acute metabolic encephalopathy and acute kidney injury with hyperkalemia with instructions to continue intravenous (IV) maintenance fluids and insulin per the hospital's DKA protocols. The note also reported the resident was diagnosed with polycythemia due to severe dehydration. Review of Resident #88's hospital nephrology consult note dated 06/28/25 revealed the resident informed the hospital medical team he still felt very bad and had felt bad for several days prior to the hospital admission and reported he was not eating well. The note stated upon hospital admission the resident had received fluids, two ampules of sodium bicarbonate (a medication used to buffer severe metabolic acidosis) and insulin. Review of Resident #88's hospital endocrinology note dated 06/28/25 revealed the resident was in a hyperglycemic hyperosmolar state (HHS) (a life-threatening complication of diabetes characterized by extremely high blood glucose levels and severe dehydration) with DKA overlap and uncontrolled diabetes with a Hemoglobin A1C goal of less than seven percent with a current reading of 11 percent The physician recommended to continue the insulin drip until the DKA resolved and transition to subcutaneous injections of Lantus (long-acting insulin) 24 units daily and Lispro eight units with a target blood glucose level of 140 to 180 mg/dL. The note stated the resident had a 365686 Page 3 of 6 365686 11/05/2025 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0684 Level of Harm - Actual harm Residents Affected - Few diagnosis of diabetes type two since 2022. Review of Resident #88's hospital physician note dated 07/02/25 revealed the resident had been admitted and treated with DKA and was off the insulin drip with continued Lantus 24 units each day and Humalog one1 unit per eight grams carbohydrate ratio. The note stated the altered mental status, DKA, and acute kidney injury had resolved. Review of Resident #88's hospital Discharge summary dated [DATE] revealed the resident was medically cleared for discharge. The resident was to be discharged with medication recommendations of 24 units of Lantus with instructions to inject 24 units every morning, Lispro insulin per sliding scale with instructions to administer if blood sugar from 150-200 mg/dL give 2 units; 201-250 mg/dL give 4 units; 251-300 mg/dL give 6 units; and 301-350 mg/dL give 8 units, and his home medication of Farxiga 10 mg once daily. During an interview on 10/29/25 at 6:10 P.M., CNA #135 stated she was working with Resident #88 the day he transferred to the hospital (06/27/25) and she notified the nurse that the resident was acting off and was not himself. She reported the resident had several episodes of being incontinent of urine which was not normal for him and he was requiring more assistance than what was normal for him. She stated he was typically independent with most activities of daily living but he was not getting out of bed. She stated he also typically was particular with his meals and that day just took what was served and only ate about 50 percent of his breakfast and lunch. CNA #135 stated Resident #88 was having increased confusion and was staring off and not as talkative or responsive as usual. She informed the nurse in the morning after breakfast. CAN #135 stated she thought the nurse had assessed the resident and checked his blood sugar and said she had talked with CNP #200 herself as she was concerned for Resident #88's health. CNA #135 stated she had heard from the nursing staff that the blood sugar was reading high meaning an actual reading of over 500. After she left her shift, the resident's family had come to the facility and demanded the resident be transferred to the hospital for an evaluation. She was told by staff working with resident the previous day (CNA #127), that Resident #88 had started showing symptoms of a change in condition on 06/26/25 and she was unsure if the nurse or CNP had evaluated him the previous day. During an interview on 10/30/25 at 10:05 A.M., Registered Nurse (RN) #139 stated she was the nurse working with Resident #88 on the day he transferred to the hospital. She stated she did not remember specific details as the change in condition occurred several months prior. RN #139 stated she was informed by CNA #135 of the resident not acting like himself. She talked with CNP #200 about the change in behaviors and took his vital signs which were within normal limits. CNP #200 instructed her to get a blood sugar reading it read high (over 500). She reported the information to CNP #200 who met with the resident and ordered a one-time Lispro insulin dose of two units with a recheck shortly thereafter. A second one-time dose and recheck was then ordered and reported both rechecks read high. When the second recheck came back high, CNP #200 had left the facility and RN #139 stated she contacted the on-call CNP #250 who ordered a sliding scale of eight units and if over 350 mg/dL to call her back. Before the re-check was due, the resident's family had come and demanded Resident #88 be transferred to the hospital. Resident #88 was transferred to the hospital around 6:15 to 6:30 P.M. and she completed a blood sugar check prior to him leaving and it was 404 mg/dL. She stated Licensed Practical Nurse (LPN) #137 was also assisting with the resident's transfer. During an interview on 10/30/25 at 10:25 A.M. with CNA #127 stated she had worked with Resident #88 the day prior to his hospital transfer (06/26/25). Resident #88 had a bowel movement accident and needed cleaned up, which was not normal for him. He was more tired than normal and less talkative. Typically, the resident ordered a bunch of extra items from the kitchen and would send staff to the kitchen several times each meal but did not on 06/26/25. She stated she and another CNA #140 noticed the change in condition and informed the nurse who came in and assessed the 365686 Page 4 of 6 365686 11/05/2025 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0684 Level of Harm - Actual harm Residents Affected - Few resident but was unsure the outcome of the assessment or whether the CNP was notified and she did not remember who the nurse was that completed the assessment/evaluation. During an interview on 10/30/25 at 11:31 A.M., CNP #200 stated Resident #88 had been non-compliant with his diet and had been ordering a large amount of food via Door Dash. After the lab result came back on 05/27/25 with an increase in the Hemoglobin A1C to 7.9 percent, she had a discussion with the pharmacist and the resident, and it was thought the increase from the Hemoglobin A1C was likely from his diet. CNP #200 discussed with the resident about making dietary changes and wanting to lose weight and each resident's needs should be assessed to determine how frequently a residents blood sugar should be checked and at what blood sugar level should the medical provider be notified. For Resident #88, staff should use nursing judgement and inform the medical provider if the blood sugar was over 180 mg/dL and stated it would be concerning to have untreated blood sugars of 300's and 400's. She acknowledged the written order stated to notify the provider for blood sugars over 400 mg/dL. She confirmed she was not informed of any blood sugars in the 300's or 400's and confirmed no one from the facility contacted her regarding the blood sugar reading of 471 mg/dL on 06/23/25. CNP #200 stated she would have assessed the resident and placed a note with new recommendations and/or orders to get the blood sugar within a normal range. CNP #200 stated she was not notified until after lunch on 06/27/25 of a concern related to a change in a condition for Resident #88. Upon assessment, Resident #88 had sluggish responses. She confirmed she was involved with care relating to the two units of insulin given twice without the resident's response and revealed further updates were given through the on-call CNP #250. During an interview on 10/30/25 at 11:45 A.M., LPN #137 stated she was working and assisted the assigned nurse [RN #139] with assessing Resident #88 and administering insulin as ordered. LPN #137 confirmed the resident was provided with a total of four units of insulin and a sliding scale amount of an additional eight units. When the resident's family arrived at the facility they were upset with staff stating they were not doing anything and not caring for the resident and demanded he be transferred out to the hospital. During an interview on 10/30/25 at 1:07 P.M., RN #138 stated she was a nurse working with the resident on 06/26/25. She stated she did not remember the CNA's informing her of any concerns or changes in condition but did state she remembered assessing Resident #88 on 06/26/25 (a Wednesday) and found no concerns. She also stated she took a blood sugar reading and reported it was high. She said she did not remember what the number was but it was likely in the 300's or 400's and confirmed it was not documented in the medical record what the result was. RN #138 also confirmed the CNP #200 was not informed of any concerns or of the blood sugar reading and stated it may have been outside the range to report. Resident #88 had a bad diet and would get extra cranberry and orange juices and he requested six packs of sugar for his drinks, so a higher reading would not be surprising to her. RN #138 was unable to explain what led to the assessment and blood sugar reading on 06/26/25, outside of the regular weekly Monday readings. During an interview on 10/30/25 at 1:15 P.M., the Director of Nursing (DON) stated the staff know the residents very well and would likely identify changes in residents behaviors and needs and revealed the facility had discussed with the CNA's to inform the nursing staff and/or management if they had concerns about a resident or noticed a change in condition. The DON acknowledged, according to Resident #88's medical record, the CNP #200 was first notified of a change in blood sugar readings on 06/27/25 and confirmed the facility had no notes from the reading of 471 mg/dL on 06/23/25 or any mentions of a change in condition, nursing assessments or blood sugar checks on 06/26/25. The DON confirmed if a resident was having a change in condition, including having a high blood sugar reading outside of the physician orders, the medical team should have been notified. The DON also confirmed once notified, the CNP should put appropriate 365686 Page 5 of 6 365686 11/05/2025 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0684 Level of Harm - Actual harm Residents Affected - Few things in place and reported two units twice (total of 4 units) of insulin, when a blood sugar was over 500 mg/dL, would likely have no effect. She stated Resident #88 should have been sent out to the hospital after getting a reading over 500 mg/dL but especially should have been sent out after giving insulin with no change in the blood sugar reading instead of continuing with small insulin amounts over several hours. The DON acknowledged the resident should have been assessed for changes after the high reading on 06/23/25 and should have had more interventions and insulin orders put in place after his Hemoglobin A1C went from 6.5 to 7.9 percent around the same time of getting a blood sugar of 300 mg/dL. The DON revealed resident should have had increased monitoring or more frequent checks being ordered to monitor if changes in Resident #88's diet were having an impact on his blood sugar readings. Review of the facility policy titled, Notifications of Change in Condition, undated, revealed the safety of the residents was of primary importance and the purpose of the policy was to provide guidance related to notifications made to residents, family members, and the medical practitioner during changes in condition. The medical provider shall be promptly notified of significant changes and the medical record must reflect the notification, response and interventions implemented to address the change in condition. Review of the facility policy titled, Blood Glucose Point of Care Testing, undated, revealed safety was the primary concern for the residents. The importance of ongoing glucose monitoring was necessary to detect extremes of high or low blood glucose levels to evaluate the effectiveness of the treatment plan. A nurse may preform a non-routine glucose blood testing at the bedside without a physician order if resident changes were indicative of low or high blood glucose levels. Extremely high blood glucose levels could result in headaches, increased urination, fatigue, fruity breath and dry mouth and if left untreated, could result in coma or death. This deficiency represents non-compliance investigated under Complaint Number 1331272. 365686 Page 6 of 6