Inspection·October 10, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Actual harm Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders and a diagnosis of diabetes resulting in hospitalization for one of five residents reviewed (Resident 2). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect, complete, and review ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 1, 2024, indicated that the resident was admitted from a hospital, was cognitively impaired, and dependent on staff for care. A nurse's note for Resident 2, dated October 3, 2024, at 10:00 a.m., revealed that the resident's blood glucose level was 923 mg/dL, and the resident was transferred to the local hospital and admitted with hyperglycemia (high blood sugar) and altered mental status. admission paperwork for Resident 2 (including discharge paperwork from the hospital and a history from the resident's primary care provider) revealed a diagnosis of diabetes mellitus, with physician's orders, dated April 30, 2024, for 6 units of Tresiba FlexTouch U-100 insulin 100 unit/ml (a medication for treatment of diabetes), and orders dated March 5, 2024, to test the resident's blood sugar twice daily. There was no documented evidence in the clinical record to indicate that Resident 2's diagnosis of diabetes or the orders for insulin and blood sugar checks were identified and clarified with the physician. Interview with Licensed Practical Nurse 1 on October 10, 2024, at 10:40 a.m. revealed that Resident 2 did not have a diagnosis of diabetes and confirmed that the resident had not received insulin or blood sugar checks since her admission to the facility. Interview with the Registered Dietician on October 10, 2024, at 11:17 a.m. revealed that on admission the resident's diet was a controlled carbohydrate diet (normally prescribed for diabetics); however, it was changed due to the resident not having a diagnosis of diabetes. The registered dietician stated that she reviewed the hospital discharge paperwork but not the paperwork from Resident 2's Primary Care Provider. (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: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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)