Health inspection·January 26, 2024

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 reviewed (Residents R9, R10, R24, and R33). 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 Diabetes - Clinical Protocol reviewed 3/6/23, indicated the physician will order desired parameters for monitoring and reporting information related to diabetes ot blood sugar management. The staff will identify and report complications. Review of the facility policy Nursing Care of the Resident with Diabetes Mellitus reviewed 3/6/23, indicated documentation should reflect the carefully assessed diabetic resident and include vital signs, level of consciousness, assessment of the skin, blood sugar results. The approximate reference ranges for hypoglycemia are: Mild hypoglycemia - 55-70 Page 1 of 6 395633 395633 01/26/2024 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0684 Moderate hypoglycemia - 40-55 Level of Harm - Minimal harm or potential for actual harm Severe hypoglycemia - <40 Residents Affected - Some Review of the facility policy Obtaining a Fingerstick Glucose Level reviewed 3/623, indicated to report results promptly to the supervisor and physician and report other information in accordance with facility policy and professional standards of practice. Review of the facility policy Change in Resident ' s Condition or Status reviewed 3/6/23, indicated the facility shall promptly notify the resident, his/her doctor, and representative of changes in the resident ' s medical/mental condition and/or status. The nurse will notify the doctor or the doctor on call when there has been a significant change in the resident ' s physical/emotional/mental condition, and when specific instructions to notify the doctor of changes in the resident ' s condition. The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status. Review of the facility policy Charting and Documentation reviewed 3/6/23, indicated all services provided to the resident, progress toward the care plan, or any changes in the resident ' s medical, physical, functional, or psychosocial condition shall be documented in the resident ' s medical record. Documentation of procedures and treatments will include care-specific details, including the date and time procedure/treatment was provided, assessment data and/or any unusual findings, and notification of family, physician, or other staff if indicated. Review of the clinical record indicated Resident R9 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and muscle weakness. Review of Resident R9 ' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 12/23/23, indicated the diagnoses remain current. Review of a physician ' s order dated 12/28/21, indicated to inject Novolog insulin per sliding scale, if blood glucose less than 70 or greater than 400 call the doctor. Further review of a physician ' s order dated 3/17/23, indicated to call the doctor if blood sugar is 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 11/5/23, at 5:37 p.m. CBG was noted to be 447. On 12/21/23, at 12:09 p.m. CBG was noted to be 65 Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, failed to follow facility protocol, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan revised 7/8/20, indicated to administer diabetic medications per physician ' s orders. Obtain glucometer readings and report abnormalities as ordered. Report symptoms of hyper-/hypoglycemia. 395633 Page 2 of 6 395633 01/26/2024 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of a clinical record indicated Resident R10 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, heart failure (progressive heart disease that affects pumping action of the heart muscles), and high blood pressure. Review of the MDS dated [DATE], indicated the diagnoses remain current. Residents Affected - Some Review of physician ' s orders dated 3/17/23, indicated to call doctor for hypo/hyperglycemic episodes or if blood sugar is less than 70/greater than 400. Further review of a physician order dated 8/17/22 indicated to inject Novolog (a 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, If blood sugar is 401 or greater give 10 units, call doctor if blood glucose is less than 70 or greater than 400. Review of Resident R10's eMAR revealed that the resident's CBG's were as follows: On 12/7/23, at 8:42 a.m. CBG was noted to be 63. On 1/14/24, at 8:32 a.m. CBG was noted to be 63. A review of Resident R10's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results. A review of Resident R10's care plan dated 12/12/18, indicated to administer insulin medications per physician orders. Report symptoms of hypo-/hyperglycemia. Further review of the care plan dated 11/23/23, indicated to obtain glucometer readings and report abnormalities as ordered. Review of the clinical record indicated Resident R24 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and anxiety. Review of Resident R24 ' s MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 4/13/23, indicated to call the doctor if blood sugar is less than 70/greater than 400. For symptomatic hypoglycemia and responsive, give rapidly absorbed glucose (juice, soda) recheck in 15 minutes and repeat if indicated. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 12/24/23, at 8:49 a.m. CBG was noted to be 53. Review of Resident R24's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 10/15/22, indicated to administer diabetic medications per physician orders. Obtain glucometer readings and report abnormalities as ordered. Report symptoms of 395633 Page 3 of 6 395633 01/26/2024 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0684 hypoglycemia. Level of Harm - Minimal harm or potential for actual harm Review of the clinical record indicated Resident R33 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and muscle weakness. Residents Affected - Some Review of Resident R33' s MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 1/4/24, indicated to call the doctor if blood sugar is less than 70/greater than 400. Inject Admelog (Lispro) per sliding scale if greater than 400 give 12 units and notify doctor. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 1/5/24, at 12:17 p.m. CBG was noted to be 429. On 1/5/24, at 4:40 p.m. CBG was noted to be 403. On 1/5/24, at 5:14 p.m. CBG was noted to be 403. On 1/22/24, at 9:30 a.m. CBG was noted to be 49. Review of Resident R33's eMAR and clinical progress notes indicated the resident was not assessed for hypo-/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 and failed to follow the physician ' s order. Review of the care plan dated 1/4/24, indicated to administer medications per physician orders. Obtain glucometer readings and report abnormalities as ordered. Report symptoms of hypo-/hyperglycemia. During an interview on 1/25/24, at 8:13 a.m. Licensed Practical Nurse (LPN) Employee E2 stated for blood sugar under 60-70, they would notify the doctor and provide a snack. If the blood sugar was over 200, they would check the orders for parameters, and call the doctor accordingly. During an interview on 1/25/24, at 8:17 a.m. Registered Nurse (RN) Employee E3 stated for blood sugars over 400, they would check the parameters, give the baseline insulin, complete an assessment, and call the provider. If the blood sugar was less than 70 they would offer a snack, call the doctor, and monitor the resident. During an interview on 1/25/24, at 8:20 a.m. RN Employee E4 stated for blood sugars over 300-400, they would check the orders for parameters, give the ordered insulin, complete an assessment and call the doctor. If the blood sugar was less than 60, follow protocol, offer snack, complete assessment, and recheck in 15 minutes. During an interview on 1/25/24, at 2:08 a.m. LPN Employee E5 stated for blood sugars less than 70 they would give snack, notify the doctor if needed and recheck in 15 minutes. For blood sugars over 400, they would give the ordered insulin, notify the doctor, and recheck in 30 minutes. During an interview on 1/26/24, at 10:30 a.m. the Director of Nursing confirmed the facility failed 395633 Page 4 of 6 395633 01/26/2024 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0684 to notify the doctor of a change in condition related to blood glucose, failed to follow the care plan interventions, and failed to recheck blood sugars for Residents R9, R10, R24, and R33. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.18 (b)(1) Management. Residents Affected - Some 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. 395633 Page 5 of 6 395633 01/26/2024 Havencrest Rehabilitation and Healthcare Center 1277 Country Club Road Monongahela, PA 15063

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of 12 residents reviewed (Resident R43). Residents Affected - Few Findings include: Review of the facility policy End-Stage Renal Disease, Care of a Resident with last reviewed on 3/6/23, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents. A review of the clinical record indicated that Resident R43 was admitted to the facility on [DATE], with diagnoses that included ESRD (the kidneys permanently fail to work), cancer, and dependence on renal dialysis. A review of the Minimum Data Set (MDS - periodic assessment of care needs) date 11/17/23, indicated the diagnoses remain current. A review of a physician ' s order dated 12/18/23, indicated Resident R43 was to receive dialysis three days a week on Monday, Wednesday, and Fridays. Review of a care plan dated 12/6/23, indicated arrange for transportation to and from dialysis facility on dialysis days. Confer with physician and/or dialysis treatment facility regarding changes in medication administration times/dosage pre-dialysis as needed. Check access site for lack of thrill/bruit, evidence of infection, swelling, or excessive bleeding. Report abnormalities to physician. Coordinate dialysis care with dialysis treatment facility. Review of the dialysis communication sheets from 12/18/23 through 1/22/24, indicated eight of eight communication sheets not completed pre-dialysis treatment, and nine communication sheets were not located. During an interview on 1/26/24, at 10:45 a.m. Registered Nurse Employee E1 confirmed the dialysis communication sheets Communication for Transition of Care between Dialysis and Skilled Nursing Facility sheets are received from the dialysis center. They are not the facility ' s communication sheets. During an interview on 1/26/23, at 10:48 a.m. the Director of Nursing confirmed the facility failed to ensure the dialysis communication forms for Resident R43 were completed following each dialysis treatment day. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395633 Page 6 of 6