Health inspection·October 6, 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 R5, R12, R15, and R29). 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 Nursing Care of the Diabetic Resident reviewed 1/12/23, indicated the facility will recognize, assist, and document the treatment of complications commonly associated with diabetes. Documentation should reflect the carefully assessed diabetic resident; document interventions to stabilize blood glucose levels and response; document notification to physician of unstable and/or variances from baseline per physician order. Review of the facility policy Notification of Condition Change: Physician reviewed 1/12/23, indicated licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a resident's condition. Document assessment data, attempted or actual correspondence with physician, and physician's response in the medical record. Page 1 of 5 396073 396073 10/06/2023 Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317

F 0684 Review of the facility Hypoglycemia Protocol Level of Harm - Minimal harm or potential for actual harm Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Residents Affected - Some Review of Resident R5's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/13/23, indicated the diagnoses remain current. Review of physician orders dated 7/10/23, 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) insulin per sliding scale before meals and to notify the doctor if blood glucose was less than 70. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 9/15/23, at 8:43 a.m. CBG was noted to be 62, confirmed at 8:44 a.m. Review of Resident R5'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 1/30/23, indicated blood glucose monitoring as ordered, administer meds per doctor order, monitor for signs and symptoms of low blood sugar, and sliding scale coverage as ordered. Review of a clinical record indicated Resident R12 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and hemiparesis (weakness of one side of the body). Review of a physician order dated 8/9/23, indicated to inject Aspart insulin per sliding scale with meals. If blood glucose is greater than 401, give 12 units and call the doctor. Review of Resident R12's eMAR revealed that the resident's CBG's were as follows: On 8/18/23, at 4:16 p.m. CBG was noted to be 417. A review of Resident R12's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, interventions were not documented, blood sugar was not rechecked, and the physician was not notified of abnormal results. A review of Resident R12's care plan dated 8/10/23, indicated to check blood glucose as ordered, call doctor per order. Observe for sign and symptoms of hyperglycemia. Provide insulin coverage as per resident's individual order. Sliding scale coverage as ordered. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and high blood pressure. Review of Resident R15's MDS dated [DATE], indicated the diagnoses remain current. 396073 Page 2 of 5 396073 10/06/2023 Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of physician orders dated 1/16/23, indicated to inject Aspart insulin per sliding scale before meals and at bedtime. Further review of a physician's order dated 1/16/23, indicated to give one applicator of Glucose Gel (dextrose gel, a form of sugar used to raise blood glucose levels in hypoglycemia) if blood glucose is less than 70. Recheck blood sugar in 10-15 minutes, may repeat one time. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 6/27/23, at 10:20 p.m. CBG was noted to be 65. On 6/1/23, at 5:09 p.m. CBG was noted to be 59. On 4/23/23, at 4:39 p.m. CBG was noted to be 61. ON 4/14/23, at 9:21 p.m. CBG was noted to be 62. On 4/14/23, at 5:49 p.m. CBG was noted to be 66. On 4/1/23, at 5:30 a.m. CBG was noted to be 53. Glucose gel administered. Review of Resident R15'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 1/17/23, indicated check blood glucose as ordered, call doctor per order. Administer meds per doctor order. Monitor/observe for signs and symptoms of hypoglycemia. Review of the clinical record indicated Resident R29 was re-admitted to the facility on with diagnoses that included diabetes, high blood pressure, and anxiety. Review of Resident R29's Minimum Data Set, dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 2/16/23, indicated to inject Humalog (Lispro) insulin 7 units before meals, and inject Glargine (long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours) 12 units once daily. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 9/19/23, at 5:46 a.m. CBG was noted to be 480. On 9/18/23, at 5:35 a.m. CBG was noted to be 409. On 9/4/23, at 6:25 p.m. CBG was noted to be 417. Confirmed at 6:26 p.m. On 9/1/23, at 8:46 p.m. CBG was noted to be 566. On 8/25/23, at 12:13 p.m. CBG was noted to be 422. 396073 Page 3 of 5 396073 10/06/2023 Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317

F 0684 On 8/21/23, at 4:27 p.m. CBG was noted to be 449. Level of Harm - Minimal harm or potential for actual harm On 8/21/23, at 3:45 p.m. CBG was noted to be 449. On 8/11/12, at 4:59 p.m. CBG was noted to be 420. Residents Affected - Some Review of Resident R29'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 10/31/17, indicated to check blood glucose as ordered, call doctor for abnormal values. Observe/monitor resident for signs and symptoms of hyperglycemia. Provide insulin coverage as per order. During an interview on 10/4/23, at 2:35 p.m. Licensed Practical Nurse (LPN) Employee E1 stated for residents on insulin less than 70 or greater than 400 unless otherwise ordered they would give the prescribed insulin and notify the doctor. For resident's less than 70, a snack or orange juice is given. Documentation is done in the progress notes. During an interview on 10/4/23, at 2:40 p.m. LPN Employee E2 stated for blood glucose levels under 70, they would give glucose or snack, assess the resident, and notify the doctor. If the resident is greater than 400 they would assess the resident, call the doctor, and document in the progress notes. During an interview on 10/4/23, at 2:45 p.m. Registered Nurse (RN) Employee E3 stated they would notify the doctor for blood glucose less than 50-60, and greater than 400 and document in the progress notes. During an interview on 10/4/23, at 2:50 p.m. LPN Employee E4 stated she would notify the doctor of blood glucose less than 70, or greater than 400. She would document in the medical record under the progress notes. She would recheck the blood glucose in 15-30 minutes and document the recheck in progress notes. During an interview on 10/4/23, at 1:55 p.m. LPN Employee E5 stated she would call the doctor for blood glucose less than 70, or greater than 400, recheck in 15 minutes, and document in the progress notes. During an interview on 10/4/23, at 4:00 p.m. LPN Employee E6 stated they would notify the doctor for blood glucose less than 70 or greater than 400. They would recheck the blood glucose in 15-30 minutes and document in the progress notes. During an interview on 10/4/23, at 4:20 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. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 396073 Page 4 of 5 396073 10/06/2023 Kadima Rehabilitation & Nursing at North Strabane 100 Tandem Village Road Canonsburg, PA 15317

F 0684 28 Pa. Code 211.10 (c)(d) Resident Care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services Residents Affected - Some 396073 Page 5 of 5