Inspection·October 7, 2024

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 a review of hospital, and clinical records, and interviews with staff, it was determined that the facility failed to properly assess, monitor, and provide treatment for a resident with known condition of diabetes resulting in the harm of hospitalization after experiencing hypoglycemia (low sugar in blood) for one of three residents reviewed (Resident CL1). Residents Affected - Few Findings include: Review of Resident CL1's clinical record revealed Resident CL1 was admitted to the facility on [DATE]. Review of Resident CL1's diagnosis list includes Diabetes Mellitus (group of metabolic disorders characterized by a high blood sugar level over a prolonged period) long-term (current use of insulin), and Chronic Kidney Disease. Review of Resident CL1's hospital records including document labeled Clinical Summary created on September 22, 2024, revealed the resident was on blood sugar monitoring three times daily. The same document indicated, regarding Resident CL1's DM (Diabetes Mellitus), with the use of insulin, the plan was to continue to monitor POTC (point-of-care test) Accuchecks (machine used to check blood glucose); Hypoglycemia and Hyperglycemia (high blood sugar) protocol in place; and encourage p.o. (by mouth) intake. Review of Resident CL1's hospital record Emergency Department Provider Notes dated September 21-22, 2024, revealed the resident's POTC glucose was checked. A laboratory report dated September 21, 2024, showed a Glucose level of 166 mg/dl (Normal range 80-130 mg/dl). Review of Resident CL1's physician orders dated September 22, 2024, revealed the following orders: Insulin Aspart Protamine & Aspart Suspension (Aspart 70/30- premixed insulin that starts to work within 10 to 20 minutes after injection, peaks in 2 hours, and keeps working for up to 24 hours) Inject 25 units two times daily.; Insulin Aspart Solution (fast-acting insulin) Inject 16 units one time a day (Scheduled at noon); Insta-Glucose Gel 77.4% Give one dose by mouth as needed for blood glucose less than 70, for a patient who is arousable conscious, and able to swallow if repeat blood glucose is below 70 mg/dl. Continue to hold all diabetic medications until the provider authorizes resumption; Glucagon Emergency Kit 1 mg Inject 1 mg intramuscularly as needed for blood glucose less than 70, not arousable conscious or able to swallow if repeat blood glucose is below 70 mg/dl and the patient is not arousable, conscious, or able to swallow. Continue to hold all diabetic medications until the provider authorizes resumption, and the Hypoglycemia protocol observes signs/symptoms of Hypoglycemia as needed if blood glucose is less than 70 mg/dl or ordered low parameters follow 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 3 Event ID: 395332 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 395332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Center 30 West Avenue Wayne, PA 19087 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)