Health inspection·September 21, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure residents and/or resident representatives were provided admission packet and admission information timely to allow the resident and/or resident representative to participate in the care process. This affected one (Resident #40) of three residents reviewed for admission information. The facility census was 46. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed an admission date of 07/19/23 with diagnoses that included diabetes mellitus and chronic obstructive pulmonary disease. Further review of the medical record including the Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 07/28/23 revealed Resident #40 was cognitively intact. Further review of the medical record found no evidence of any admission paperwork within the medical record. Interview with Resident #40's representative on 09/21/23 at 8:49 A.M. indicated the resident or herself were not provided with an admission packet upon admission. She indicated Resident #40 and herself were provided the admission packet approximately two weeks ago, nearly two months after admission. Interview with Resident #40 on 09/21/23 at 9:00 A.M. indicated she was not provided an admission packet timely upon admission. She indicated herself and her representative were provided an admission packet approximately two weeks ago. She further indicated she is unaware of the facility rules. Interview with Admissions Coordinator #105 on 09/21/23 at 10:10 A.M. verified no admission packet has been completed for and signed by Resident #40 and her representative. She further indicated she met with Resident #40 and her representative about two weeks ago, but the representative took the packet home to review and has not returned the information. This deficiency represents non-compliance investigated under Complaint Number OH00146265. Page 1 of 4 366241 366241 09/21/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, review of information from diabetes.org and interview the facility failed to adequately monitor Resident #40 related to the administration of diabetic medication. Actual harm occurred on 07/22/23 when Resident #40 was found by staff with a change in mental status/condition after oral hypoglycemic medications had been adjusted and no routine blood glucose monitoring was ordered/completed. Resident #40 was emergently transferred to the hospital and subsequently admitted with a diagnosis of hypoglycemia (low blood glucose/sugar level). This affected one resident (#40) of three residents reviewed for blood glucose monitoring. The facility census was 46. Findings include: Review of Resident #40's medical record revealed an admission date of 07/19/23 with diagnoses that included diabetes mellitus (long term) and chronic obstructive pulmonary disease. Further review of the medical record including the Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 07/28/23 revealed Resident #40 had intact cognition. Review of admission medication orders revealed Resident #40 was prescribed metformin (diabetic medication) 500 milligram (mg) tablet twice daily and Tresiba (diabetic medication) 12 units subcutaneous weekly. Following admission on [DATE] Resident #40's physician evaluated the resident and changed her diabetic medications. The Tresiba was discontinued, glipizide (diabetic medication) five mg twice daily was added, and metformin was increased to 1000 mg twice daily. There was no physician order for blood glucose monitoring (BGM) upon admission or after evaluation by the physician. Review of a nursing note revealed on 07/22/23 at 8:00 P.M. revealed Resident #40 was sitting up on the edge of the bed and suddenly fell back onto the bed and wasn't answering questions or following commands. Upon assessment, the resident was laying flat. A neurological assessment showed the resident was unable to grip the nurse's hands and her left eye was deviating outward. At 8:05 P.M. 911 was activated to have the resident transported to the emergency room for a change in mental status and possible stroke symptoms. There was no documented evidence that the resident's blood glucose level was checked or considered a potential issue as part of the resident's assessment at the time of this acute change in condition. The resident was admitted to the hospital with a diagnosis of hypoglycemia (low blood glucose level). There was no documented evidence the resident's blood glucose was assessed prior to her hospital transfer, in the ambulance or as part of the resident's history and physical at the hospital. Review of the hospital history and physical dated 07/23/23 revealed the resident was brought to the hospital from the facility for altered mental status. The resident was found to be hypoglycemic upon emergency medical services arrival and subsequently brought to the emergency department. After several rounds of glucose replacement with oral glucose and intravenous ampules of dextrose the resident's mental status had improved and had returned to baseline; however, the resident had reoccurring hypoglycemia requiring ampules of dextrose and finally IV dextrose drip initiation. 366241 Page 2 of 4 366241 09/21/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0757 Level of Harm - Actual harm Residents Affected - Few Further review of the medical record revealed the resident returned to the facility on [DATE] with orders to decrease the metformin to 500 mg twice a day and orders to check the resident's blood glucose levels before meals and at bedtime. Interview with Resident #40's representative on 09/21/23 at 8:49 A.M. revealed upon admission there was no blood glucose monitoring (BGM) completed and the resident had a hypoglycemic episode resulting in transfer and admission to the hospital. Interview with Resident #40 on 09/21/23 at 9:00 A.M. revealed upon admission the facility the physician changed her diabetic medications and they were not monitoring her blood glucose level. The resident stated she was confused and weak and she fell over in bed three days after admission when her blood sugar dropped, and staff had to send her to the hospital. Interview with Registered Nurse (RN) #109 on 09/21/23 at 11:25 A.M. verified Resident #40 was admitted to the facility without BGM while on diabetic medications and had diabetic medication changes shortly after admission. RN #109 further verified Resident #40 was transferred and admitted to the hospital on [DATE] for hypoglycemia. Interview with Resident #40's physician on 09/21/23 at 1:40 P.M. revealed diabetic medication changes were made upon admission due to the Tresiba medication not being on the pharmacy formulary. The physician further indicated he assumed Resident #40 was already ordered BGM and BGM should have been completed due to the resident being diabetic and having diabetic medication changes. Review of the diabetes.org website revealed hypoglycemia is the technical term for low blood glucose. It's when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range. Here are a few causes: too much insulin or oral diabetic medication, and too little food. The deficiency was corrected on 08/16/23 when the facility implemented the following corrective actions: Review of the facility survey history revealed a deficiency was issued during a survey completed on 07/07/23 related to the lack of monitoring and timely care of a resident with diabetes mellitus resulting in a significant change in condition and hospitalization. Resident #40 was admitted to the facility on [DATE]. On 07/01/23 the facility implemented a plan to monitor for ongoing compliance weekly for two months and then monthly on a continuing basis thereafter. The monitoring would specifically audit Glucagon vials were available in the emergency crash cart in the training center through direct visual inspection of the crash cart. Pharmacy would also complete their own audit of Glucagon vials being present in emergency crash cart during their normal monthly visits. These audits were completed by the facility Risk Management Team which consists of the MDS RN, Administrator, DON/IP and CO-DON. Additionally, the DON/IP, CO-DON & MDS RN would audit any other resident who was admitted in the future for actual bloods sugar amounts and correct dose (of insulin) administered through direct observation of nurse when taken and administered. The monitoring would also be accomplished through chart review and direct observation of the electronic medication administration record (EMAR) and electronic treatment administration record (ETAR). The monitoring would also include auditing signs and symptoms section of the ETAR that nurses are now signing every shift. This monitoring would be completed three 366241 Page 3 of 4 366241 09/21/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0757 times a week with a different nurse each time for one month beginning 07/01/23 and then weekly for 2 months thereafter. Level of Harm - Actual harm Residents Affected - Few The facility reviewed concerns in their Quality Assessment Performance Improvement (QAPI) for effectiveness and compliance during a meeting initially on 07/06/23. The facility then reviewed recommendations as a result of QAPI by 08/16/2023. The facility implemented new standing orders in point click care (PCC) for any resident that is a diabetic is to have blood sugars to be checked before and after meals and at night. This systemic change would ensure that staff would be reminded on the ETAR to obtain the resident's blood sugar even if a resident was not on insulin but a diabetic. This was completed for Resident #40 upon re-admission on [DATE]. The facility implemented a plan for all diabetic residents to have laminated signs placed in their rooms by facility nursing staff to assist all staff in identifying signs and symptoms of high and low blood sugars. The facility Resident Navigator would monitor that these signs were placed upon admission through direct observation and visual inspection of resident's room. This monitoring began on 07/31/23 and was to be completed as residents were admitted and weekly for all current residents who were diabetic. The facility implemented a plan for any newly hired staff to receive education/training as part of the orientation process. This education would be provided by the DON/RN and Personnel Director as well as designated facility staff completing the training for the new employee. The facility indicated the QAPI committee would meet again in August 2023 to determine effectiveness and compliance with all corrective actions. Between 08/16/23 and 09/21/23 no additional resident concerns were identified related to diabetic monitoring and/or incidents of hypoglycemia for residents. This deficiency represents non-compliance investigated under Complaint Number OH00146265. 366241 Page 4 of 4