Health inspection·November 18, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for three of 12 residents reviewed (Resident R15, R35, and R38). Findings include: Review of the facility policy Advanced Directive last reviewed 9/30/21 and 10/3/22, indicated that information will be provided upon admission if the resident has not formulated an advance directive. Review of the medical record indicated Resident R15 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, Alzheimer ' s Disease (type of brain disorder that causes problems with memory, thinking and behavior), and high blood pressure. Review of Resident R15 Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/27/22, indicated the diagnoses remain current. Review of the clinical record failed to reveal an advanced directive or documentation that Resident R15 was given the opportunity to formulate an Advanced Directive. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, diabetes, and depression. Review of Resident R35's MDS dated [DATE], indicated the diagnoses remain current. Review of the clinical record failed to reveal an advanced directive or documentation that Resident R35 was given the opportunity to formulate an Advanced Directive. Review of the clinical record indicated Resident R38 was re-admitted to the facility on [DATE], with diagnoses that included depression, stroke (blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), difficulty swallowing, and anxiety. Review of Resident R38's MDS dated [DATE], indicated the diagnoses remain current. Review of the clinical record failed to reveal an advanced directive or documentation that Resident Page 1 of 6 395873 395873 11/18/2022 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0578 R38 was given the opportunity to formulate an Advanced Directive. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/17/22, at 2:40 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the clinical record did not include documentation that Residents R15, R35, and R38 were afforded the opportunity to formulate Advanced Directives. Residents Affected - Few 28 Pa. Code: 201.29(a)(b)(c)(d)(j) Resident rights. Previously cited 11/4/21, 3/15/18, and 9/17/18. 395873 Page 2 of 6 395873 11/18/2022 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0610 Respond appropriately to all alleged violations. 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, facility documentation and staff interviews, it was determined the facility failed to investigate one of four skin tears reviewed (Resident R41) Residents Affected - Few Findings include: Review of facility policy Incident and Accident Reports dated 10/3/22, indicated that an incident is defined as any happening that is not consistent with the routine operation of the facility. The incident is documented on an Incident report form and forwarded to the supervisor for follow-up. Review of Resident R41's clinical record indicated was admitted [DATE] with diagnosis of Alzheimers (progressive mental deterioration due to degeneration of the brain), Dementia (chronic disorder of the mental processes caused by brain disease or injury marked by memory disorder, personality changes, and impaired reasoning) and Type 2 Diabetes Mellitus. Review R41's MDS assessment (minimum data assessment-periodic assessment of resident care needs) indicated the diagosis remained current. Review of nursing progress notes dated 10/19/22 indicated Resident R41 sustained a skin tear to right wrist, u shaped. No incident report was noted for Resident R41's skin tear. During an interview on 11/16/22, at 2:45 p.m. , the Director of Nursing confirmed that the facility failed to complete a skin tear investigation for Resident R41. 28 PA. Code: 201.14(a)responsibility of licensee 28 PA. Code: 201.18(e)(10 (4) Management 395873 Page 3 of 6 395873 11/18/2022 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

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 two of six Residents (Residents R15, and R20). Residents Affected - Few 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 Hypoglycemia protocol last reviewed 9/30/21 and 10/3/22, indicated the purpose was to treat residents with blood sugars below 70. Review of the facility policy Hyperglycemia protocol last reviewed 9/30/21 and 10/3/22, indicated the purpose was to treat residents with elevated blood sugars. Review of the facility policy Change in Resident Status/Condition last reviewed 9/30/21 and 10/3/22, indicated the resident should have a head-to-toe assessment completed by a nurse, notify the physician of change in condition, and documentation will be made in the resident chart. Review of the medical record indicated Resident R15 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), and high blood pressure. Review of Resident R15's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/27/22, indicated the diagnoses remain current. Review of a physician order dated 9/13/22, indicated to check CBG before meals and at bedtime for seven days without coverage. Further review of a physician order dated 9/19/22, indicated to inject 34 units of insulin glargine (long-acting insulin administered by subcutaneous injection for the 395873 Page 4 of 6 395873 11/18/2022 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0684 management of diabetes)at bedtime. Level of Harm - Minimal harm or potential for actual harm Review of Resident R15's electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: Residents Affected - Few On 10/24/22, at 8:08 p.m., CBG was noted to be 425. On 9/23/22, at 8:39 p.m., CBG was noted to be 433. On 9/21/22, at 7:21 p.m., CBG was noted to be 413. On 9/19/22, at 7:46 p.m., CBG was noted to be 415. On 9/19/22, at 3:15 p.m., CBG was noted to be 425. On 9/17/22, at 8:17 p.m., CBG was noted to be 431. On 9/14/22, at 7:18 p.m., CBG was noted to be 539. On 9/13/22, at 8:53 p.m., CBG was noted to be 456. Review of Resident R15's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 9/20/22, indicated to give diabetes medication as ordered and monitor/document side effects and effectiveness, and to monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia to MD as needed. Review of a clinical record indicated Resident R20 was admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and high blood pressure. Review of Resident R20's MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 6/18/22, indicated to check CBG before meals with sliding scale insulin coverage. Further review of the physician orders revealed glucagon (a hormone that your pancreas makes to help regulate your blood glucose) one milligram (mg) injection as needed for hypoglycemia, and glucose gel 40% (used to treat low blood sugar ) as needed for hypoglycemia. Review of current active orders for Resident R20, indicated the above orders are still current. Review of Resident R20's eMAR revealed that the resident's CBG's were as follows: On 9/24/22, at 9:47 a.m., CBG was noted to be 65. On 9/17/22, at 10:56 a.m., CBG was noted to be 69. On 8/18/22, at 7:35 a.m., CBG was noted to be 66. 395873 Page 5 of 6 395873 11/18/2022 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0684 On 7/28/22, at 8:56 a.m., CBG was noted to be 62. Level of Harm - Minimal harm or potential for actual harm On 7/2/22, at 10:13 a.m., CBG was noted to be 62. Residents Affected - Few Review of Resident R20's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, interventions were not documented, blood sugar was not rechecked, physician orders were not followed regarding facility's hypoglycemic protocol, and the physician was not notified of abnormal results on the above listed dates. Review of Resident R20's care plan dated 10/1/21, indicated to give diabetes medication as ordered and monitor/document side effects and effectiveness, and to monitor/document/report signs and symptoms of hypoglycemia to MD as needed. Review of the care plan indicated interventions were not in place at the time of hypoglycemic episodes until 10/13/22. During an interview on 11/18/22, at 8:40 a.m. Licensed Practical Nurse (LPN) Employee E1 stated for residents with hyper-/hypoglycemia she would follow protocol, assess the resident, notify the physician, and document in the residents' chart. During an interview on 11/18/22, at 8:50 a.m. Registered Nurse (RN) Employee E2 stated for residents with hyper-/hypoglycemia she would follow protocol, assess the resident, notify the physician, re-check the blood glucose, and document in the residents' chart. During an interview on 11/18/22, at 9:50 a.m., the Director of Nursing confirmed the facility failed to document hypo/hyperglycemic episodes, failed to follow hypoglycemic protocols, and failed to notify the MD of changes in condition for Residents R15, and R20. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c) Resident Care policies 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12 (d)(1)(2)(3) Nursing services 28 Pa. Code 211.12 (d)(5) Nursing Services 395873 Page 6 of 6