Health inspection·July 26, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **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 provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eleven of nineteen residents reviewed (Resident R3, R21, R38, R43, R89, R100, R105, R117, R147 ,R187, R214). Findings Include: A review of the facility policy Advanced Directives: Patient Self Determination Act and PA Act 169 dated 1/2/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses that included diabetes(high blood sugar), high blood pressure, congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and morbid (severe) obesity. A review of the clinical record failed to reveal an advance directive or documentation that Resident R3 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R21 was admitted to the facility on [DATE], with diagnoses that included diabetes, hypertensive heart disease (uncontrolled high blood pressure), and dysphagia (difficulty swallowing). A review of the clinical record failed to reveal an advance directive or documentation that Resident R21 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R38 was admitted to the facility on [DATE], with diagnoses that included dysphagia, high blood pressure, congestive heart failure(chronic condition in which the heart doesn't pump blood as well as it should), and anemia(not having enough healthy red blood cells). A review of the clinical record failed to reveal an advance directive or documentation that Resident R38 was given the opportunity to formulate an Advanced Directive. Page 1 of 9 395643 395643 07/26/2024 John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the medical record indicated Resident R43 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, chronic obstructive pulmonary disease (COPD-a combination of lung diseases that block airflow and make it difficult to breathe), and dysphagia. A review of the clinical record failed to reveal an advance directive or documentation that Resident R43 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R89 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, congestive heart failure, and dysphagia. A review of the clinical record failed to reveal an advance directive or documentation that Resident R89 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R100 was admitted to the facility on [DATE], with diagnoses that included hemiplegia(loss of motor skills on one side of the body), high blood pressure, peripheral vascular disease(condition in which narrowed blood vessels reduce blood flow to the limbs) and obesity. A review of the clinical record failed to reveal an advance directive or documentation that Resident R100 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R105 was admitted to the facility on [DATE], with diagnoses that included high blood pressure and peripheral vascular disease. A review of the clinical record failed to reveal an advance directive or documentation that Resident R105 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R117 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, dysphagia and morbid (severe) obesity. A review of the clinical record failed to reveal an advance directive or documentation that Resident R117 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R147 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, congestive heart failure, and dysphagia. A review of the clinical record failed to reveal an advance directive or documentation that Resident R147 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R187 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and obesity. A review of the clinical record failed to reveal an advance directive or documentation that Resident R187 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R214 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, congestive heart failure, and dysphagia. A review of the clinical record failed to reveal an advance directive or documentation that 395643 Page 2 of 9 395643 07/26/2024 John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207

F 0578 Resident R214 was given the opportunity to formulate an Advanced Directive. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/25/2024, at 11:32 a.m. the DON confirmed that the clinical record did not include documentation that Resident R3, R21, R38, R43, R89, R100, R105, R117, R147, R187, and R214 were afforded the opportunity to formulate Advance Directives. Residents Affected - Some 28 PA. Code 201.29(b)(d)(j) Resident rights. 395643 Page 3 of 9 395643 07/26/2024 John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207

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 12 residents reviewed (Residents R13, R89, R147, and R198). 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 General Guidelines reviewed 3/27/24, indicated the nurse must verify all practitioner orders to ensure all required information/directions are included. Staff must monitor the resident ' s status and condition and respond to significant changes promptly. Staff must document all care and services provided to the resident. Review of the facility policy Notification of Change in Resident Condition and Treatment Changes reviewed 3/27/24, indicated to assess the resident ' s condition, document findings and notifications in the nurses' notes. Review of the facility policy Emergency Care Guidelines: Hypoglycemic Protocol reviewed 3/27/24, indicated blood glucose monitor (BGM) reading less than 70 and symptomatic or less than 60 regardless of symptoms indicated to hold all diabetic medications and insulin until reviewed by physician, administer four ounces of soda or juice followed by four ounces of milk, recheck BGM in 15 minutes, treat according to protocol, and notify physician. Review of the Contour next EZ Blood Glucose Monitoring System User Guide 2020 edition, indicated a HI reading is a test result above 600 mg/dl. Review of the clinical record indicated Resident R13 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and congestive heart failure (chronic, 395643 Page 4 of 9 395643 07/26/2024 John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207

F 0684 Level of Harm - Minimal harm or potential for actual harm progressive condition in which the heart muscle is unable to pump enough blood through the heart to meet the body's needs for blood and oxygen). Review of Resident R13's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 7/4/24, indicated the diagnoses remain current. Residents Affected - Some Review of a physician ' s order dated 5/23/24, 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) per sliding scale, if fingerstick is over 340, give 6 units, call MD (doctor). Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 6/7/24, at 8:54 p.m. the CBG was noted to be 52. On 6/8/24, at 10:02 p.m. the CBG was noted to be HI. Review of the care plan dated 4/20/24, indicated to administer medication per MD order. Monitor for signs and symptoms of hyper-/hypoglycemia. Accuchecks as needed. Notify MD for hypo-/hyperglycemic episodes per order. 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, and the physician was not notified of abnormal results on the above listed dates. Review of a clinical record indicated Resident R89 was admitted to the facility on [DATE], with diagnoses that included diabetes, difficulty swallowing, and depression. Review of physician's orders dated 6/14/24, indicated 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) per sliding scale, if blood sugar is less than 50, call MD. Review of Resident R89's eMAR revealed that the resident's CBG's were as follows: On 6/29/24, at 7:50 a.m. the CBG was noted to be 43. On 7/14/24, at 4:47 p.m. the CBG was noted to be 41. On 7/22/24, at 8:11 a.m. the CBG was noted to be 43. Review of Resident R89's care plan dated 5/7/24, indicated to administer medication per MD order. Monitor for signs and symptoms of hyper-/hypoglycemia. Accuchecks as needed. Notify MD for hypo-/hyperglycemic episodes per order. Review of Resident R89'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. 395643 Page 5 of 9 395643 07/26/2024 John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the clinical record indicated Resident R147 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, muscle weakness, and open wounds. Review of a physician order dated 4/11/24, indicated Humalog (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) per sliding scale, if blood sugar is greater than 340, call MD. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 4/16/24, at 8:51 p.m. the CBG was noted to be 359. On 5/6/24, at 9:46 p.m. the CBG was noted to be 377. On 5/7/24, at 10:30 p.m. the CBG was noted to be 346. On 5/8/24, at 10:45 a.m. the CBG was noted to be 360. On 5/11/24, at 9:03 p.m. the CBG was noted to be 398. On 5/12/24, at 4:51 p.m. the CBG was noted to be 349. On 5/12/24, at 9:42 p.m. the CBG was noted to be 342. On 5/29/24, at 11:39 a.m. the CBG was noted to be 350. On 5/30/24, at 1:14 p.m. the CBG was noted to be 352. On 6/28/24, at 8:32 p.m. the CBG was noted to be 352. Review of the care plan dated 10/26/23, indicated to administer medication per MD order. Monitor for signs and symptoms of hyper-/hypoglycemia. Accuchecks as needed. Notify MD for hypo-/hyperglycemic episodes per order. Review of Resident R147's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, 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 clinical record indicated Resident R198 was admitted to the facility on [DATE], with diagnoses that included diabetes and high blood pressure. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 1/25/24 and 4/22/24, indicated Lispro insulin per sliding scale, if blood glucose is greater than 340 call MD. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: 395643 Page 6 of 9 395643 07/26/2024 John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207

F 0684 On 4/6/24, at 10:06 a.m. the CBG was noted to be 401. Level of Harm - Minimal harm or potential for actual harm On 4/16/24, at 11:02 a.m. the CBG was noted to be 434. On 6/2/24, at 8:58 a.m. the CBG was noted to be 372. Residents Affected - Some On 6/4/24, at 9:36 a.m. the CBG was noted to be 428. On 6/5/24, at 9:13 a.m. the CBG was noted to be 346. On 6/6/24, at 8:05 a.m. the CBG was noted to be 351. Review of the care plan dated 1/24/24, indicated to administer medication per MD order. Monitor for signs and symptoms of hyper-/hypoglycemia. Accuchecks as needed. Notify MD for hypo-/hyperglycemic episodes per order. Review of Resident R198'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. During an interview on 7/25/24, at 9:36 a.m. Licensed Practical Nurse (LPN) Employee E6 stated for any blood glucose less than 70 they would follow the hypoglycemic protocol and call the doctor. For blood glucose over 200, they would be concerned, follow the ordered sliding scale, check the resident ' s orders, administer ordered insulin, recheck the blood glucose in 30-45 minutes, and monitor the resident. They would document in the eMAR and progress notes. During an interview on 7/25/24, at 9:39 a.m. Registered Nurse (RN) Employee E7 stated if the blood glucose was less than 70, they would give a snack and recheck the blood glucose in 15-30 minutes. If the blood glucose was over 300, they would check the resident ' s chart to see their baseline and notify the doctor. They would document in the eMAR and progress notes. During an interview on 7/25/24, at 9:50 a.m. LPN Employee E8 stated if the blood glucose was under 70, they would give the resident a snack or juice. If the blood glucose was over 300, they would check the orders, follow the parameters, and call the doctor. They would document in the progress notes. During an interview on 7/25/24, at 10:00 a.m. LPN Employee E9 stated if the blood glucose was under 50, they would assess the resident and call the doctor. If the blood glucose was greater than 400, they would check vital signs, assess the resident, notify the supervisor and call the doctor. They would document in the eMAR and progress notes. During an interview on 7/25/24, at 10:05 a.m. LPN Employee E10 stated if the blood glucose was less than 70, they would give glucose gel, notify the supervisor, recheck blood glucose in 15 minutes, and call the doctor. If blood glucose was over 400, they would administer the ordered insulin and call the doctor. They would document in the progress notes, even if the doctor was present and notified verbally. During an interview on 7/25/24, at 1:00 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 R13, R89, R147, 395643 Page 7 of 9 395643 07/26/2024 John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207

F 0684 and R198. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. Residents Affected - Some 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services. 395643 Page 8 of 9 395643 07/26/2024 John J Kane Regional Center-Gl 955 Rivermont Drive Pittsburgh, PA 15207

F 0944 Level of Harm - Potential for minimal harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of facility documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for four of ten staff members (Employees E2, E3, E4, and E5). Findings include: Review of the Facility Assessment dated 7/12/24, previously reviewed 4/2/24, 1/5/24, revealed a list of required educational topics, and included in that list was QAPI - Mission, Vision, and Values. Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI program. Nurse Aide Employee E2 had a hire date of 6/16/14, failed to have QAPI in-service education between 6/16/23, and 6/16/24. Environmental Services Employee E3 had a hire date of 6/2/80, failed to have QAPI in-service education between 6/2/23, and 6/2/24. Administrative Employee E4 had a hire date of 5/31/16, failed to have QAPI in-service education between 5/31/23, and 5/31/24. Unit Clerk Employee E5 had a hire date of 7/17/00, failed to have QAPI in-service education between 7/17/23, and 7/17/24. During an interview on 7/26/24, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on the QAPI program for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395643 Page 9 of 9