Inspection·July 2, 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 record review, interview, and facility policy review, the facility failed to ensure blood glucose testing (BGT) was completed per the physician's order. This finding affected one (Resident #150) of three residents reviewed for BGT. The facility census was 140. Residents Affected - Few Findings include: Review of Resident #150's medical record revealed the resident was admitted on [DATE] with diagnoses including encephalopathy, type two diabetes, and dementia. Resident #150 was discharged on 03/27/25. Review of Resident #150's physician orders revealed an order dated 03/11/25 (discontinued 03/22/25) for a general diet, soft and bite sized texture, thin liquid consistency; and an order dated 03/23/25 for a consistent carbohydrate diet, regular texture, thin liquid consistency (CCD). Review of Resident #150's physician orders revealed an order dated 03/11/25 (discontinued 03/15/25) for sliding scale insulin coverage. The order listed Humalog (fast acting insulin) and provided the following additional parameters: if the blood sugar was zero to 180 inject no insulin; 181 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units; and call provider above 400 before meals and at bedtime. Review of Resident #150's progress note dated 03/14/25 at 12:36 P.M. revealed the power-of-attorney (POA) contacted the facility with concerns/requests. The POA was concerned that staff were waking the resident up during the night for care and medications. The resident requested medication administration times be changed to during the day while the resident was awake. The Nurse Practitioner (NP) was updated and agreeable with the time change. The POA also requested the resident should not be woken up for check and changes during the night as well as not be woken up for breakfast. Per the POA, the family was always in the building around breakfast time and would help the resident with meals if needed. The POA requested for the door to the room to be shut half way due to the light in the hallway. Review of Resident #150's physician orders revealed an order dated 03/15/25 (discontinued 03/21/25) for sliding scale insulin coverage. The order listed Humalog and provided the following additional parameters per sliding scale: if the blood sugar was zero to 180 inject no insulin; 181 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units, 351 to 400 inject ten units and call provider if above 400 before meals and at bedtime. Review of Resident #150's Medication Administration Record (MAR) for March 2025 revealed the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366071 Printed: 05/15/2026 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 366071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MT Alverna Home Inc 6765 State Road Parma, OH 44134 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)