Health inspection·April 20, 2023

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 Based on review of clinical records and staff interviews, it was determined that the facility failed to follow a physician's order regarding diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period) treatment for two of 18 residents reviewed (Residents 2 and 85). Residents Affected - Few Findings include: Review of Resident 2's Physician's Order Sheet (POS) dated January 12, 2023, revealed the following orders: Check blood sugar three times a day with a scheduled time at 7:30 a.m., 11:30 a.m., and 4:30 p.m. An order on the same day was also made to inform the physician if the blood glucose level results are greater than 450 mg/dl (blood glucose level). Review of Resident 2's March 2023 Medication Administration Records (MAR) revealed a blood sugar of 475 mg/dl on March 2, 2023, at 4:30 p.m. Further review of Resident 2's clinical record failed to reveal the physician was notified of the blood sugar result of 475 mg/dl on March 2, 2023. Review of Resident 2's April 2023 MAR revealed an order initiated on December 30, 2020, to administer Novolog (fast-acting insulin) 10 units subcutaneously (Insertion of medications beneath the skin either by injection or infusion) at 11:30 a.m. The MAR further revealed on April 11, 2023, the ordered blood sugar check and Novolog 10 units ordered at 11:30 a.m., were not done, with documentation that the resident was out of the facility. At 4:30 p.m., on the same day, Resident 2's blood sugar was 469 mg/dl. Review of the progress notes dated April 11, 2023, at 3:02, revealed resident attended a Walmart outing. The clinical records review failed to reveal that the physician was notified of the missed blood sugar check and ordered Novolog 10 units at 11:30 a.m. There was no evidence that the physician was also notified of the blood sugar of 469mg/dl at 4:30 p.m. Review of Resident 85's POS dated March 8, 2023, revealed an order for Insulin Aspart (A fast-acting insulin) sliding scale coverage before meals and at bedtime: 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; >400- 12 units and notify provider. Nursing notes dated March 8, 2023, at 1:51 p.m., revealed that the above order was made by the NP (Nurse Practitioner) after being informed of a blood sugar of 568 at 8:00 a.m., and a blood sugar of Page 1 of 3 395367 395367 04/20/2023 Oxford Health Center 7 East Locust Street Oxford, PA 19363

F 0684 507 at noon. Level of Harm - Minimal harm or potential for actual harm Review of the March 2023 MAR revealed a blood sugar of 427 mg/dl on March 8, 2023, at 4:30 p.m., the resident was administered a sliding scale order of 12 units of insulin. Residents Affected - Few The clinical records review failed to reveal that the physician was notified of Resident 85's blood sugar of 427 mg/dl at 4:30 p.m. Interview with licensed nurse Employee E3 was conducted on April 19, 2023, at 10:00 a.m. Employee E3 confirmed that the physician should be notified immediately of a blood sugar result above the ordered parameter for possible additional orders. Employee E3 reported that documentation of the blood sugar result, conversation with the physician, and possible new orders are documented in the resident's clinical record. Interview with the Director of Nursing was conducted on April 20, 2023, at 11:30 a.m. The DON confirmed that there was no documented evidence that the physician was notified of the following: Resident 2's elevated blood sugar result on March 2, 2023, and April 11, 2023, at 4:30 p.m.; Resident 2's missed blood sugar check and ordered Novolog insulin on April 11, 2023, at 11:30 a.m.; and Resident 95 's blood sugar of 427 on March 8, 2023, at 4:30 p.m. The facility failed to ensure Resident 2's and Resident 85's physician's order for their diabetic treatment was followed. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 395367 Page 2 of 3 395367 04/20/2023 Oxford Health Center 7 East Locust Street Oxford, PA 19363

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of facility policy, review of personnel records, and interviews with staff, it was determined that the facility failed to ensure newly hired employees received the abuse training outlined in their policy for two of 5 personnel records reviewed (Employees E4 and E5). Findings include: Review of facility policy Abuse Neglect or Exploitation last revised October 24. 2022 revealed that all employees would be trained on abuse, neglect, mistreatment of residents, and misappropriation of resident's property prior to being assigned to resident care areas. Training would include education on facility policy, interventions on dealing with aggressive residents, reporting abuse without fear of reprisal, recognizing burnout, what constitutes abuse, what constitutes reasonable suspicion of crime, definition of serious bodily harm, responsibility for reporting abuse, consequences of not reporting abuse and resident's right to privacy. Review of Dietary Aide, Employee E4's personnel record revealed a hire date of January 28, 2023. Further review of Employee E4's personnel record failed to reveal any completed abuse training. Review of CNA, Employee E5's personnel record revealed a hire date of February 3, 2023. Further review of Employee E5's personnel record failed to reveal any completed abuse training. Interview with the Nursing Home Administrator and Director of Nursing on April 20, 2023, at 1:30 p.m. confirmed that there was no completed abuse training in the personnel file for CNA, Employee E5 and Dietary Aide E4. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (b) Management 395367 Page 3 of 3