Health inspection·December 6, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a person-centered comprehensive care plan for one of eight residents (Resident R38). Findings include: A review of the facility policy Comprehensive Care Plans reviewed 1/30/23 and 7/19/24, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident\, consistent with resident rights. That include measurable objectives, and timeframes to meet a resident ' s medical, nursing, mental and psychosocial needs that are identified in the resident ' s comprehensive assessment. A review of the clinical record revealed Resident R38 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/29/24, indicated the diagnoses remain current. Further review of the MDS Section N: Medications, Question N0350 indicated Resident R38 received insulin injections seven days a week. A review of the admission Assessment completed 8/7/23, indicated a goal of Resident R38 was to have no complications related to diabetes. A review of a physician order dated 8/7/23, indicated to give glucose gel (to treat low blood sugar) give 15 gram by mouth for glucose 50-69. Review of a physician order dated 12/21/23, indicated to inject Humulin R insulin (short-acting insulin that starts within 30 minutes and peaks in two to three hours, and keeps working for eight hours) per sliding scale. If results are less than 70 follow hypoglycemic protocol. A review of the clinical record failed to reveal a person-centered care plan was developed for Resident R38 to address interventions relating to diabetes care. During an interview on 12/4/24, at 11:35 a.m. Registered Nurse admission Coordinator (RNAC) Employee E1 confirmed Resident R38 ' s care plan did not include person-centered interventions for diabetes. 28 Pa. Code: 211.12 (d) (1) (5) Nursing services. Page 1 of 4 395032 395032 12/06/2024 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

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 review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for two of five residents reviewed (Residents R7, and R38). Residents Affected - Few Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Notification of Change reviewed 7/19/2024, indicated the facility will ensure to promptly inform the resident, consults the resident's physician, and notifies the resident's representative, if applicable, when there is a change requiring notification. Circumstances requiring notification include accidents, significant change is resident status, and circumstances that require a need to alter treatment. Review of the facility policy Hypoglycemic Management reviewed 7/19/2024, indicated if the blood glucose reading is 70 or below, the nurse will utilize the hypoglycemic protocol as per practitioner's orders, with follow up blood glucose as indicated, and notify the practitioner of the results ordered. The blood sugar(s) and treatment will be documented as per facility protocol. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and high blood pressure. Review of Resident R7's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/24/2024, indicated the diagnoses remain current. Review of a physician's order dated 8/11/2024 to 8/15/2024, indicated Accuchecks (machine used to check the blood glucose level) three times a day and at bedtime. Call MD (doctor) for blood sugar less than 80 or over 250. A physician's order dated 8/15/2024, indicated to inject Humalog (fast-acting 395032 Page 2 of 4 395032 12/06/2024 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) eight units every morning and bedtime. Hold if blood glucose is less than 100. Use Freestyle Libre to obtain blood sugar. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 8/13/2024, at 8:50 p.m. CBG was noted to be 299. On 8/14/2024, at 4:43 p.m. CBG was noted to be 273. On 8/14/2024, at 8:24 p.m. CBG was noted to be 311. On 8/28/2024, at 6:44 a.m. CBG was noted to be 53. On 12/3/2024, at 4:32 p.m. CBG was noted to be 431. Review of the care plan dated 5/14/2019, indicated the following interventions: blood sugar as needed for symptoms of hypo/hyperglycemia, monitor/document/report signs and symptoms hyper-/hypoglycemia, diabetes medication as ordered by doctor. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of a clinical record indicated Resident R38 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and high blood pressure. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician's orders dated 8/7/2023, Glucose Oral Gel give 15 grams by mouth as needed for glucose 50-69. An order dated 9/19/2023, indicated Glucose Oral Gel give 30 grams by mouth as needed for low blood glucose. Further review of the physician orders dated 4/22/2024, indicated Freestyle Libre 14-day Sensor (continuous glucose system sensor), one unit every 14 days for blood glucose monitoring. An order dated 12/21/2023, indicated to inject Humulin R insulin (short-acting insulin that starts within 30 minutes and peaks in two to three hours, and keeps working for eight hours) per sliding scale on every Monday, Wednesday, Friday, and Sunday, if below 70 follow hypoglycemic protocol, if greater than 400 call MD. Review of Resident 38's eMAR revealed that the resident's CBG's were as follows: On 12/1/2024, at 5:20 a.m. the CBG was noted to be 54. A review of Resident R38's care plan dated 7/30/2024, indicated the following interventions: Monitor/document/report as needed signs and symptoms of hyper-/hypoglycemia. Review of Resident R38's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, failed to follow interventions of the care plan, blood sugar was not 395032 Page 3 of 4 395032 12/06/2024 McMurray Hills Rehabilitation and Healthcare Cente 249 West McMurray Road McMurray, PA 15317

F 0684 rechecked, physician orders were not followed, and the physician was not notified of abnormal results. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/4/2024, at 1:50 p.m. Licensed Practical Nurse (LPN) Employee E2 stated for blood glucose results under 70, they would give juice and/or snacks, and recheck the blood glucose in 15 minutes. If blood glucose was greater than 400, they would check the orders for parameters, they would give the ordered dose of insulin, call the doctor, and document in the nurse's notes. Residents Affected - Few During an interview on 12/4/2024, at 1:55 p.m. LPN Employee E5 stated if the blood glucose was under 70, they would give a snack or juice. If the blood glucose was greater than 350 - 400, they would give the ordered insulin, call the doctor, and recheck the blood glucose in 15-30 minutes. They would document in the nurse's notes. During an interview on 12/4/2024, at 2:02 p.m. LPN Employee E3 stated if the blood glucose was less than 70, they would give juice or snacks. If blood glucose was over 400, they call the doctor and follow the orders received. They would document in nurse's notes. During an interview on 12/4/2024, at 2:45 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physicians orders for Residents R7, and R38. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services. 395032 Page 4 of 4