Health inspection·September 28, 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 **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 four of seven Residents (Residents R53, R64, R71, and R76). Residents Affected - Some 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 Medication Administration: Disposable, Pre-filled Insulin Pen reviewed 1/12/23, indicated the nurse monitors resident for adverse reactions, including hypoglycemia, and reports adverse effects to practitioner promptly and documents in EMR (electronic medical record). Review of the facility policy Emergency Care Guidelines: Hypoglycemia Protocol reviewed 1/12/23, indicated for Blood Glucose Monitor (BGM) reading less than 70 and symptomatic or less than 60 regardless of symptoms to recheck BGM in 15 minutes, treat according to protocol, and notify physician. For BGM less than 50, recheck BGM in 15 minutes and notify the physician. Review of the facility policy Notification of Change in Resident Condition and Treatment Changes reviewed 1/12/23, indicated the facility fully informs the resident, or notify the resident ' s representative, when there is a change in condition or treatment. The nurse assesses the resident ' s condition, notifies physician of changes, and documents findings and notifications in the nurse ' s notes. The nurse notifies the resident and responsible party, where applicable, of changes in physician order and documents notification in nurse ' s notes. Review of the clinical record indicated Resident R53 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Review of Resident R53 ' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395617 If continuation sheet Page 2 of 6 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 395617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-SC 300 Kane Boulevard Pittsburgh, PA 15243 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)

F 0684 and care needs) dated 9/13/23, indicated the diagnoses remain current. Level of Harm - Minimal harm or potential for actual harm Review of physician orders dated 10/6/22, indicated to inject Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin per sliding scale with meals and at bedtime and to notify the doctor if blood glucose was less than 70. Residents Affected - Some Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 8/25/23, at 8:14 a.m. the CBG was noted to be 69. On 8/9/23, at 7:56 a.m. the CBG was noted to be 62. Review of Resident R53's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/18/23, indicated to monitor for hypoglycemia symptoms, administer insulin per order, monitor BGMs and use sliding scale provided for coverage. Review of a clinical record indicated Resident R64 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and dementia (group of symptoms that affects memory, thinking, and interferes with daily life). Review of Resident R64 ' s MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 2/12/20, indicated to inject Novolog insulin per sliding scale three times a day, notify the doctor if blood glucose is less than 70. Review of Resident R64's eMAR revealed that the resident's CBG's were as follows: On 8/16/23, at 11:35 a.m. CBG was noted to be 62. On 8/8/23, at 11:25 a.m. CBG was noted to be 60. On 8/7/23, at 12:02 p.m. CBG was noted to be 67. On 8/3/23, at 11: 16 a.m. CBG was noted to be 58. On 8/1/23, at 11:27 a.m. CBG was noted to be 66. On 7/13/23, at 11:29 a.m. CBG was noted to be 51. On 7/8/23, at 6:12 p.m. CBG was noted to be 65. On 7/3/23, at 11:18 a.m. CBG was noted to be 65. On 4/21/23, at 12:20 p.m. CBG was noted to be 54. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395617 If continuation sheet Page 3 of 6 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 395617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-SC 300 Kane Boulevard Pittsburgh, PA 15243 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)

F 0684 On 4/9/23, at 12:34 p.m. CBG was noted to be 66. Level of Harm - Minimal harm or potential for actual harm On 3/26/23, at 4:58 p.m. CBG was noted to be 53. On 3/7/23, at 4:24 p.m. CBG was noted to be 49. Residents Affected - Some On 2/26/23, at 5:27 p.m. CBG was noted to be 64. On 2/25/23, at 5:16 p.m. CBG was noted to be 57. On 2/13/23, at 4:12 p.m. CBG was noted to be 53. On 2/12/23, at 5:07 p.m. CBG was noted to be 54. A review of Resident R64's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, interventions were not documented, blood sugar was not rechecked, and the physician was not notified of abnormal results. A review of Resident R64 ' s care plan dated 8/21/22, indicated to administer insulin per doctors order, observe for side effects and effectiveness. Observe for sign and symptoms of hyper- or hypoglycemia. Obtain blood sugars as ordered. Review of the clinical record indicated Resident R71 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, and dementia. Review of Resident R71 ' s MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 5/22/23, indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) 4 units with meals, and to inject Lantus (glargine insulin - long-acting insulin that starts to work several hours after injection) 30 units once daily in the morning. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 8/17/23, at 7:43 a.m. the CBG was noted to be 65. On 5/1/23, at 10:55 a.m. the CBG was noted to be 68. Review of Resident R71's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 5/11/23, indicated administer insulin injections per orders. Observe for signs and symptoms of hyper- or hypoglycemia. Review of the clinical record indicated Resident R76 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, and anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395617 If continuation sheet Page 4 of 6 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 395617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-SC 300 Kane Boulevard Pittsburgh, PA 15243 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident R76 ' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 7/28/23, indicated the diagnoses remain current. Review of physician orders dated 1/25/23, indicated to inject NovoLog insulin per sliding scale before meals and at bedtime. If BGM is less than 70, or greater then 400, call the doctor. Further review of physician orders dated 5/23/23, indicated to inject Lispro insulin per sliding scale before meals and at bedtime. If BGM is less than 70, or greater than 400, call the doctor. A physician order dated 7/21/23, continued the Lispro insulin per sliding scale and notification parameters of less than 70 or greater than 400. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 9/22/23, at 1:15 p.m. CBG was noted to be 469. On 6/20/23, at 11:58 a.m. CBG was noted to be 40. On 5/10/23, at 11:55 a.m. CBG was noted to be 460. Review of Resident R76's eMAR and clinical progress notes indicated the resident was not assessed for hyper- or hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/11/23, indicated to administer insulin injections per ordered. Observe resident for signs and symptoms of hyper- or hypoglycemia, notify doctor with results that are out of range as ordered. During an interview on 9/26/23, at 1:20 p.m. Registered Nurse (RN) Employee E1 stated for residents on insulin, the doctor is notified depending on resident orders and test results, usually less than 70 and greater than 400 unless otherwise ordered. There is an on-call service available after 5:00 p.m., if a doctor is notified of results it is documented in the progress notes of the resident ' s clinical record. During an interview on 9/26/23, at 1:40 p.m. Licensed Practical Nurse (LPN) Employee E2 stated for blood glucose levels under 60, they would start the hypoglycemic protocol, and if greater than 400 they would assess the resident, call the doctor, and document in the progress notes. During an interview on 9/26/23, at 1:45 p.m. LPN Employee E3 stated they would follow the hypoglycemic protocol for blood glucose less than 60, and greater than 400 they would call the doctor and document in the progress notes. During an interview on 9/26/23, at 1:55 p.m. RN Employee E4 stated she would call the doctor or the on-call service for blood glucose over 400 and document in the progress notes of the clinical record. During an interview on 9/27/23, at 2:40 p.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose for Residents R53, R64, R71, and R76. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395617 If continuation sheet Page 5 of 6 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 395617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John J Kane Regional Center-SC 300 Kane Boulevard Pittsburgh, PA 15243 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)

F 0684 28 Pa. Code 201.18 (b)(1) Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29(d) Resident Rights. 28 Pa. Code 211.10 (c)(d) Resident Care policies. Residents Affected - Some 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395617 If continuation sheet Page 6 of 6