Health inspection·October 1, 2024

F 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to ensure that residents were provided a written notice of his or her rights and services provided, as well as all rules and regulations governing resident conduct and responsibilities during their stay in the facility prior to or upon admission for two of four residents (Residents R2 and R3). Residents Affected - Few Findings include: Review of the facility provided admission Packet included: application for admission, personal information, legal representation, choice of funeral home, income information, provision of services, charges and billing, Medicare/Medicaid programs, personal finances, transfers, bed holds, resident responsibilities, personal properly, notice of privacy practices, authorization of treatment, grievance procedures, and the facility arbitration agreement. Review of resident records conducted on 10/1/24, revealed the following: Resident R2 was admitted on [DATE], with no signed admission agreement, or authorization to treat until 8/21/24. Resident R3 was admitted on [DATE], with no signed admission agreement, or authorization to treat present in resident record. During an interview on 10/1/24, at 3:33 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that residents were provided a written notice of his or her rights and services provided, as well as all rules and regulations governing resident conduct and responsibilities during their stay in the facility prior to or upon admission for two of four residents. 28 Pa. Code: 201.29(a)(c)(e) Resident rights. Page 1 of 16 395883 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of a change in condition for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Acute Condition Changes - Clinical Protocol dated [DATE], indicated before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). Review of facility policy Management of Hypoglycemia dated [DATE], indicated symptoms of hypoglycemia (low blood sugar level) may include: - Weakness, dizziness, or fainting - Restlessness and/or muscle twitching - Increased heart rat - Pale, cool, moist skin - Excessive sweating - Irritability or bizarre changes in behavior - Blurred or impaired vision - Headaches - Numbness of the tongue and the lips/thick speech More severe symptoms include: - Stupor (a state of near-unconsciousness), unconsciousness and/or convulsions (sudden uncontrolled electrical disturbances in the brain which can cause changes in behavior, movements, feelings, and consciousness) - Coma (a state of prolonged unconsciousness where the patient cannot respond to external stimuli). Classification of hypoglycemia: 395883 Page 2 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Level 1 hypoglycemia: blood glucose less than 70 mg/dL (milligrams per deciliter) but greater than 54 mg/dL; - Level 2 hypoglycemia: blood glucose is less than 54 mg/dL and; - Level 3 hypoglycemia: altered mental status and/or physician status requiring assistance for treatment of hypoglycemia Treatments for hypoglycemia levels include: - For Level 1 hypoglycemia, give the resident an oral form of rapidly absorbed glucose (15-20 grams), notify the provider immediately, remain with the resident, and recheck blood glucose in 15 minutes. - For Level 2 hypoglycemia, administer glucagon (a medication used to increase blood sugar levels) (intranasal [via the nose], intramuscular [into a muscle], or as provided), notify the provider immediately, remain with the resident, place resident in a comfortable and safe place, monitor vital signs, and recheck blood glucose in 15 minutes. - For Level 3 hypoglycemia and is unresponsive, call 911, administer glucagon (intranasal, intramuscular, or as provided), notify the provider immediately, remain with the resident, place the resident in a safe place, and monitor vital signs. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated [DATE], indicated diagnoses of muscle weakness, anemia (too little iron in the blood) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a Nursing Note dated [DATE], at 8:09 a.m. completed by Licensed Practical Nurse (LPN) Employee E2 stated, Called to resident's room by Nurse Aide. Resident not responding appropriately and foam coming from nose and mouth. Vital signs as follows: blood pressure: 148/66, temperature: 98.2 degrees Fahrenheit, heart rate: 90, respirations: 20. Blood glucose 46 mg/dL. Glucose gel (a medication given orally to increase blood sugar). Supervisor aware. Review of a Nursing Note dated [DATE], at 8:30 a.m. completed by LPN Employee E2 stated, Resident's blood glucose rechecked 99 mg/dL. Resident continues to have foam coming from mouth and nose. Not responding appropriately. Supervisor aware. Review of a Nursing Note dated [DATE], at 9:30 a.m. completed by LPN Employee E2 stated, Resident blood glucose checked again 46 mg/dL, more glucose gel given. Supervisor informed. Resident continues to have foam from mouth and nose. Review of a Nursing Note dated [DATE], at 10:24 a.m. completed by LPN Employee E2 stated, Rechecked blood glucose it is 42 mg/dL. Glucose gel given. Supervisor aware. Review of a Nursing Note dated [DATE], at 10:45 a.m. completed by LPN Employee E2 stated, Resident's blood glucose rechecked 33 mg/dL. 395883 Page 3 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a Nursing Note dated [DATE], at 10:48 a.m. completed by LPN Employee E2 stated, Gave resident glucagon subcutaneously (an injection given into the fatty tissue layer between skin and muscle) in left deltoid (a muscle in the shoulder). Per supervisor order was obtained. Review of a Nursing Note dated [DATE], at 10:50 a.m. completed by Registered Nurse (RN) Employee E3 stated, At 10:50 a.m. I was notified by nursing staff that the resident wasn't responding to most questions being asked. Physician, Nursing Home Administrator, and Director of Nursing were made aware of resident's condition. Nursing stated that resident's blood sugar was 46 mg/dL. Nursing was asked if resident seemed to be lethargic. Upon entering room, resident was cold to touch, no pulse, and no rise to the chest was noted. Code Blue and emergency medical service (EMS) was called immediately. CPR (cardiopulmonary resuscitation) was initiated by Supervisor until EMS arrived and they continued with chest compression. CPR continued until resident CTB (ceased to breathe) at 12:03 p.m. which was called by EMS. Review of a Nursing Note dated [DATE], at 11:00 a.m. completed by LPN Employee E2 stated, Called to residents room by supervisor. Resident without pulse. This writer left room to obtain oxygen. Returned to room. Supervisor doing compressions on mattress. EMS arrived and moved resident to the floor. Review of a Nursing Note dated [DATE], at 12:34 p.m. completed by LPN Employee E2 stated, EMS provide care. ROSC (return of spontaneous circulation - resumption of a sustained heart rhythm that circulates blood throughout the body) obtained for 10 minutes. Then returned to asystole (heart's electrical system fails and stops beating). EMS called time of death 12:03 p.m. During an interview on [DATE], at 11:31 a.m. LPN Employee E2 stated, On [DATE], the aides were delivering breakfast trays and yelled for me to come. Resident R1 was not responding appropriately and was foaming from her mouth. I yelled for an aide to call the RN Supervisor on the supervisor phone. I took her vitals, and her blood sugar level was very low. The RN Supervisor came up and assessed her and I asked the Supervisor to please obtain an order for glucagon when she spoke to the physician. I gave Resident R1 oral glucose gel, her blood sugar came up. She was still foaming from the mouth and nose and still not responding appropriately. I told the Supervisor and asked her about talking to the physician, the Supervisor stated she had not spoken to the physician yet. Resident R1's blood sugar dropped again, and I told the Supervisor we should probably send her to the hospital. I'm not sure when or if the Supervisor spoke to the physician. The Supervisor called me to the desk at 10:45 a.m. and had the physician on speaker phone. The physician was asking me questions and wanted to know what was going on. The physician gave an order to send Resident R1 to the hospital and an order for glucagon. She had already had several doses of the oral glucose gel. I gave her the glucagon. The Supervisor went into Resident R1's room and saw the resident was without a pulse and respirations. I came out for the crash cart and oxygen, when I came back in the room EMS was putting the resident on the floor. On [DATE], at 10:33 a.m. when asked how long it took the RN Supervisor to initially respond and assess Resident R1, LPN Employee E2 stated, It took a while for the supervisor to come, I'd say about 20 minutes. State Agency (SA) attempted to call RN Employee E3 to obtain a statement on [DATE], at 11:55 a.m. RN Employee E3 did not return a phone call to SA. During an interview on [DATE], at 12:17 p.m. the Director of Nursing (DON) stated, That situation was a mess, I was made aware of it last week. The notification time is horrendous, I don't understand 395883 Page 4 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0580 Level of Harm - Minimal harm or potential for actual harm why they didn't jump straight to administering glucagon. I spoke with the physician, and she stated she was not made aware of the severity of the situation until around 10:40 a.m. During an interview on [DATE], at 12:17 p.m. the DON confirmed that the facility failed to ensure the physician was appropriately notified of a change in condition as required. Residents Affected - Few 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 395883 Page 5 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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, job descriptions, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of the facility's Licensed Practical Nurse (LPN) Supervisor job description indicated the LPN will prepare and administer medications as ordered by the physician. Review of facility policy Administering Medications dated 3/27/24, indicated the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of facility policy Intramuscular Injections dated 3/27/24, indicated an intramuscular (a technique used to deliver a medication deep into the muscles, allowing the bloodstream to absorb the medication quickly) injection can be administered in the following sites: - Vastus lateralis (the outside muscle of the thigh) - Ventrogluteal (an area of the muscle on the side of the hip) - Dorsogluteal (an area of the muscle in the upper buttocks) - Deltoid (a muscle in the shoulder) Review of facility policy Management of Hypoglycemia dated 3/27/24, indicated symptoms of hypoglycemia (low blood sugar level) may include: - Weakness, dizziness, or fainting - Restlessness and/or muscle twitching - Increased heart rat - Pale, cool, moist skin - Excessive sweating - Irritability or bizarre changes in behavior - Blurred or impaired vision - Headaches - Numbness of the tongue and the lips/thick speech 395883 Page 6 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0658 More severe symptoms include: Level of Harm - Minimal harm or potential for actual harm - Stupor (a state of near-unconsciousness), unconsciousness and/or convulsions (sudden uncontrolled electrical disturbances in the brain which can cause changes in behavior, movements, feelings, and consciousness) Residents Affected - Few - Coma (a state of prolonged unconsciousness where the patient cannot respond to external stimuli). Classification of hypoglycemia: - Level 1 hypoglycemia: blood glucose less than 70 mg/dL (milligrams per deciliter) but greater than 54 mg/dL; - Level 2 hypoglycemia: blood glucose is less than 54 mg/dL and; - Level 3 hypoglycemia: altered mental status and/or physician status requiring assistance for treatment of hypoglycemia Treatments for hypoglycemia levels include: - For Level 1 hypoglycemia, give the resident an oral form of rapidly absorbed glucose (15-20 grams), notify the provider immediately, remain with the resident, and recheck blood glucose in 15 minutes. - For Level 2 hypoglycemia, administer glucagon (intranasal [via the nose], intramuscular [into a muscle], or as provided), notify the provider immediately, remain with the resident, place resident in a comfortable and safe place, monitor vital signs, and recheck blood glucose in 15 minutes. - For Level 3 hypoglycemia and is unresponsive, call 911, administer glucagon (a medication used to increase blood sugar levels) (intranasal, intramuscular, or as provided), notify the provider immediately, remain with the resident, place the resident in a safe place, and monitor vital signs. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/28/24, indicated diagnoses of muscle weakness, anemia (too little iron in the blood) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a Nursing Note dated 9/2/24, at 8:09 a.m. completed by LPN Employee E2 stated, Called to resident's room by Nurse Aide. Resident not responding appropriately and foam coming from nose and mouth. Vital signs as follows: blood pressure: 148/66, temperature: 98.2 degrees Fahrenheit, heart rate: 90, respirations: 20. Blood glucose 46 mg/dL. Glucose gel (a medication given orally to increase blood sugar). Supervisor aware. Review of a Nursing Note dated 9/2/24, at 8:30 a.m. completed by LPN Employee E2 stated, Resident's blood glucose rechecked 99 mg/dL. Resident continues to have foam coming from mouth and nose. Not responding appropriately. Supervisor aware. 395883 Page 7 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a Nursing Note dated 9/2/24, at 9:30 a.m. completed by LPN Employee E2 stated, Resident blood glucose checked again 46 mg/dL, more glucose gel given. Supervisor informed. Resident continues to have foam from mouth and nose. Review of a Nursing Note dated 9/2/24, at 10:24 a.m. completed by LPN Employee E2 stated, Rechecked blood glucose it is 42 mg/dL. Glucose gel given. Supervisor aware. Review of a Nursing Note dated 9/2/24, at 10:45 a.m. completed by LPN Employee E2 stated, Resident's blood glucose rechecked 33 mg/dL. Review of a Nursing Note dated 9/2/24, at 10:48 a.m. completed by LPN Employee E2 stated, Gave resident glucagon subcutaneously (an injection given into the fatty tissue layer between skin and muscle) in left deltoid. Per supervisor order was obtained. During an interview on 10/1/24, at 11:31 a.m. when asked if it is appropriate to give a resident, who is visibly foaming at the mouth and not responding appropriately, an oral medication, LPN Employee E2 stated, I was rubbing the glucose gel in her gums and cheeks, I wasn't dumping it in her mouth to choke her. During an interview on 10/1/24, at 11:31 a.m. when asked how she administered the glucagon, LPN Employee E2 stated, I gave it subcutaneously, I thought that's how it was supposed to be given. During an interview on 10/1/24, at 12:17 p.m. the Director of Nursing (DON) stated that he would expect a resident, who was visibly foaming at the mouth and not responding appropriately, would not have anything placed in their mouth. The DON confirmed that per facility policy, Glucagon is to be administered intranasal, intramuscular, or as provided. During an interview on 10/1/24, at 12:17 p.m. the DON confirmed that the facility failed to provide care and services to meet the accepted standards of practice as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. 395883 Page 8 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

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 record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to implement the facility's hypoglycemia protocol and failing to notify the physician timely of a change in condition for one of five residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of facility policy Acute Condition Changes - Clinical Protocol dated [DATE], indicated before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). Review of facility policy Management of Hypoglycemia dated [DATE], indicated symptoms of hypoglycemia (low blood sugar level) may include: - Weakness, dizziness, or fainting - Restlessness and/or muscle twitching - Increased heart rat - Pale, cool, moist skin - Excessive sweating - Irritability or bizarre changes in behavior - Blurred or impaired vision - Headaches - Numbness of the tongue and the lips/thick speech More severe symptoms include: - Stupor (a state of near-unconsciousness), unconsciousness and/or convulsions (sudden uncontrolled electrical disturbances in the brain which can cause changes in behavior, movements, feelings, and consciousness) - Coma (a state of prolonged unconsciousness where the patient cannot respond to external stimuli). Classification of hypoglycemia: 395883 Page 9 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Level 1 hypoglycemia: blood glucose less than 70 mg/dL (milligrams per deciliter) but greater than 54 mg/dL; - Level 2 hypoglycemia: blood glucose is less than 54 mg/dL and; - Level 3 hypoglycemia: altered mental status and/or physician status requiring assistance for treatment of hypoglycemia Treatments for hypoglycemia levels include: - For Level 1 hypoglycemia, give the resident an oral form of rapidly absorbed glucose (15-20 grams), notify the provider immediately, remain with the resident, and recheck blood glucose in 15 minutes. - For Level 2 hypoglycemia, administer glucagon (intranasal [via the nose], intramuscular [into a muscle], or as provided), notify the provider immediately, remain with the resident, place resident in a comfortable and safe place, monitor vital signs, and recheck blood glucose in 15 minutes. - For Level 3 hypoglycemia and is unresponsive, call 911, administer glucagon (a medication used to increase blood sugar levels) (intranasal, intramuscular, or as provided), notify the provider immediately, remain with the resident, place the resident in a safe place, and monitor vital signs. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated [DATE], indicated diagnoses of muscle weakness, anemia (too little iron in the blood) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a Nursing Note dated [DATE], at 8:09 a.m. completed by Licensed Practical Nurse (LPN) Employee E2 stated, Called to resident's room by Nurse Aide. Resident not responding appropriately and foam coming from nose and mouth. Vital signs as follows: blood pressure: 148/66, temperature: 98.2 degrees Fahrenheit, heart rate: 90, respirations: 20. Blood glucose 46 mg/dL. Glucose gel (a medication given orally to increase blood sugar). Supervisor aware. Review of a Nursing Note dated [DATE], at 8:30 a.m. completed by LPN Employee E2 stated, Resident's blood glucose rechecked 99 mg/dL. Resident continues to have foam coming from mouth and nose. Not responding appropriately. Supervisor aware. Review of a Nursing Note dated [DATE], at 9:30 a.m. completed by LPN Employee E2 stated, Resident blood glucose checked again 46 mg/dL, more glucose gel given. Supervisor informed. Resident continues to have foam from mouth and nose. Review of a Nursing Note dated [DATE], at 10:24 a.m. completed by LPN Employee E2 stated, Rechecked blood glucose it is 42 mg/dL. Glucose gel given. Supervisor aware. Review of a Nursing Note dated [DATE], at 10:45 a.m. completed by LPN Employee E2 stated, Resident's blood glucose rechecked 33 mg/dL. Review of a Nursing Note dated [DATE], at 10:48 a.m. completed by LPN Employee E2 stated, Gave 395883 Page 10 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident glucagon subcutaneously (an injection given into the fatty tissue layer between skin and muscle) in left deltoid (a muscle in the shoulder). Per supervisor order was obtained. Review of a Nursing Note dated [DATE], at 10:50 a.m. completed by Registered Nurse (RN) Employee E3 stated, At 10:50 a.m. I was notified by nursing staff that the resident wasn't responding to most questions being asked. Physician, Nursing Home Administrator, and Director of Nursing were made aware of resident's condition. Nursing stated that resident's blood sugar was 46 mg/dL. Nursing was asked if resident seemed to be lethargic. Upon entering room, resident was cold to touch, no pulse, and no rise to the chest was noted. Code Blued and emergency medical service (EMS) was called immediately. CPR (cardiopulmonary resuscitation) was initiated by Supervisor until EMS arrived and they continued with chest compression. CPR continued until resident CTB (ceased to breathe) at 12:03 p.m. which was called by EMS. Review of a Nursing Note dated [DATE], at 11:00 a.m. completed by LPN Employee E2 stated, Called to residents room by supervisor. Resident without pulse. This writer left room to obtain oxygen. Returned to room. Supervisor doing compressions on mattress. EMS arrived and moved resident to the floor. Review of a Nursing Note dated [DATE], at 12:34 p.m. completed by LPN Employee E2 stated, EMS provide care. ROSC (return of spontaneous circulation - resumption of a sustained heart rhythm that circulates blood throughout the body) obtained for 10 minutes. Then returned to asystole (heart's electrical system fails and stops beating). EMS called time of death 12:03 p.m. During an interview on [DATE], at 11:31 a.m. LPN Employee E2 stated, On [DATE], the aides were delivering breakfast trays and yelled for me to come. Resident R1 was not responding appropriately and was foaming from her mouth. I yelled for an aide to call the RN Supervisor on the supervisor phone. I took her vitals, and her blood sugar level was very low. The RN Supervisor came up and assessed her and I asked the Supervisor to please obtain an order for glucagon when she spoke to the physician. I gave Resident R1 oral glucose gel, her blood sugar came up. She was still foaming from the mouth and nose and still not responding appropriately. I told the Supervisor and asked her about talking to the physician, the Supervisor stated she had not spoken to the physician yet. Resident R1's blood sugar dropped again, and I told the Supervisor we should probably send her to the hospital. I'm not sure when or if the Supervisor spoke to the physician. The Supervisor called me to the desk at 10:45 a.m. and had the physician on speaker phone. The physician was asking me questions and wanted to know what was going on. The physician gave an order to send Resident R1 to the hospital and an order for glucagon. She had already had several doses of the oral glucose gel. I gave her the glucagon. The Supervisor went into Resident R1's room and saw the resident was without a pulse and respirations. I came out for the crash cart and oxygen, when I came back in the room EMS was putting the resident on the floor. On [DATE], at 10:33 a.m. when asked how long it took the RN Supervisor to initially respond and assess Resident R1, LPN Employee E2 stated, It took a while for the supervisor to come, I'd say about 20 minutes. State Agency (SA) attempted to call RN Employee E3 to obtain a statement on [DATE], at 11:55 a.m. RN Employee E3 did not return a phone call to SA. During an interview on [DATE], at 12:17 p.m. the Director of Nursing (DON) stated, That situation was a mess, I was made aware of it last week. The notification time is horrendous, I don't understand why they didn't jump straight to administering glucagon. I spoke with the physician, and she stated 395883 Page 11 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0684 she was not made aware of the severity of the situation until around 10:40 a.m. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE], at 12:17 p.m. the DON confirmed that the facility failed to make certain that residents were provided appropriate treatment and care by failing to implement the facility's hypoglycemia protocol and failing to notify the physician timely of a change in condition as required. Residents Affected - Few 28 Pa. Code 201.18 (b)(1) Management. 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. 395883 Page 12 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0760 Ensure that residents are free from significant medication errors. 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 record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of the facility's Licensed Practical Nurse (LPN) Supervisor job description indicated the LPN will prepare and administer medications as ordered by the physician. Review of facility policy Administering Medications dated 3/27/24, indicated the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of facility policy Intramuscular Injections dated 3/27/24, indicated an intramuscular (a technique used to deliver a medication deep into the muscles, allowing the bloodstream to absorb the medication quickly) injection can be administered in the following sites: - Vastus lateralis (the outside muscle of the thigh) - Ventrogluteal (an area of the muscle on the side of the hip) - Dorsogluteal (an area of the muscle in the buttocks) - Deltoid (a muscle in the shoulder) Review of facility policy Management of Hypoglycemia dated 3/27/24, indicated classification of hypoglycemia (low blood sugar level) include: - Level 1 hypoglycemia: blood glucose less than 70 mg/dL (milligrams per deciliter) but greater than 54 mg/dL; - Level 2 hypoglycemia: blood glucose is less than 54 mg/dL and; - Level 3 hypoglycemia: altered mental status and/or physician status requiring assistance for treatment of hypoglycemia Treatments for hypoglycemia levels include: - For Level 1 hypoglycemia, give the resident an oral form of rapidly absorbed glucose (15-20 grams), notify the provider immediately, remain with the resident, and recheck blood glucose in 15 minutes. - For Level 2 hypoglycemia, administer glucagon (a medication used to increase blood sugar levels) (intranasal [via the nose], intramuscular [into a muscle], or as provided), notify the provider immediately, remain with the resident, place resident in a comfortable and safe place, monitor vital 395883 Page 13 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0760 signs, and recheck blood glucose in 15 minutes. Level of Harm - Minimal harm or potential for actual harm - For Level 3 hypoglycemia and is unresponsive, call 911, administer glucagon (intranasal, intramuscular, or as provided), notify the provider immediately, remain with the resident, place the resident in a safe place, and monitor vital signs. Residents Affected - Few Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/28/24, indicated diagnoses of muscle weakness, anemia (too little iron in the blood) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician's order dated 8/24/24, indicated to administer Lantus (a long-acting insulin) inject 1 unit subcutaneously (an injection given into the fatty tissue layer between skin and muscle) at bedtime for diabetes. Review of Resident R1's August 2024 Medication Administration Record (MAR) indicated Lantus was not administered as ordered on 8/28/24, at 9:00 p.m. Review of Resident R1's September 2024 MAR indicated Lantus was not administered as ordered on 9/1/24, at 9:00 p.m. Review of a Nursing Note dated 9/2/24, at 8:09 a.m. completed by LPN Employee E2 stated, Called to resident's room by Nurse Aide. Resident not responding appropriately and foam coming from nose and mouth. Vital signs as follows: blood pressure: 148/66, temperature: 98.2 degrees Fahrenheit, heart rate: 90, respirations: 20. Blood glucose 46 mg/dL. Glucose gel (a medication given orally to increase blood sugar). Supervisor aware. Review of a Nursing Note dated 9/2/24, at 8:30 a.m. completed by LPN Employee E2 stated, Resident's blood glucose rechecked 99 mg/dL. Resident continues to have foam coming from mouth and nose. Not responding appropriately. Supervisor aware. Review of a Nursing Note dated 9/2/24, at 9:30 a.m. completed by LPN Employee E2 stated, Resident blood glucose checked again 46 mg/dL, more glucose gel given. Supervisor informed. Resident continues to have foam from mouth and nose. Review of a Nursing Note dated 9/2/24, at 10:24 a.m. completed by LPN Employee E2 stated, Rechecked blood glucose it is 42 mg/dL. Glucose gel given. Supervisor aware. Review of a Nursing Note dated 9/2/24, at 10:45 a.m. completed by LPN Employee E2 stated, Resident's blood glucose rechecked 33 mg/dL. Review of a Nursing Note dated 9/2/24, at 10:48 a.m. completed by LPN Employee E2 stated, Gave resident glucagon subcutaneously in left deltoid. Per supervisor order was obtained. During an interview on 10/1/24, at 11:31 a.m. when asked how she administered the glucagon, LPN Employee E2 stated, I gave it subcutaneously, I thought that's how it was supposed to be given. During an interview on 10/1/24, at 12:17 p.m. the Director of Nursing (DON) confirmed that per 395883 Page 14 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0760 Level of Harm - Minimal harm or potential for actual harm facility policy, Glucagon is to be administered intranasal, intramuscular, or as provided. The DON also confirmed that Lantus was not documented as administered. During an interview on 10/1/24, at 12:17 p.m. the DON confirmed that the facility failed to ensure that residents are free of significant medication errors as required. Residents Affected - Few 28 Pa. Code: 211.12(d)(1)(3)(5)Nursing services. 28 Pa. Code: 201.29(b)(d)(j) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.9 (k)(l)(1)(2) Pharmacy services. 395883 Page 15 of 16 395883 10/01/2024 Burgh Care Center 909 West Street Pittsburgh, PA 15221

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation and staff interview it was determined that the facility failed to ensure infection control and prevention practices were implemented on one of two nursing units observed (3rd floor). Residents Affected - Few Findings include: Review of facility policy Infection Control Plan dated 12/11/23, indicated the facility would ensure that the highest standards of Infection Control Practices are met. During an observation on 10/1/24, at 12:30 p.m., revealed urine soaked linens on Resident R4's bed during lunch service. Resident R4 stated that NA's would be back after lunch to get them. During an interview on 10/1/24 at 2:15 p.m., Nursing Home Administrator and Director of Nursing confirmed that the facility failed to properly maintain infection control practices for the 3rd floor. 28 Pa. Code 207.2(a) Administrators Responsibility 28 Pa. Code 211.10(c)(d) Resident care policies 395883 Page 16 of 16