Glenbrook Rehabilitation & Skilled Nursing Center

hydrocodone-acetaminophen was to be given to Resident C four times a day.A review of the MAR, dated 8/1/25-8/31/25, indicated Lantus insulin was not documented as given or refused on 8/1/25 and 8/10/25.

Blood glucose was not recorded on 8/31/25 at 6 pm. No documentation of Lispro administration was found on 8/1/25 at 6:00 PM for a glucose of 272, 8/4/25 at noon for a glucose of 255. No administration or refusal of Lispro was indicated on 8/31/25. 42 units of Lantus were given between 7:00 PM and 10:00 PM without a recorded blood glucose measurement. No documentation of hydrocodone-acetaminophen administration or refusal was indicated on 8/21/25 at 12:00 AM. 3. A record review for Resident D began on 11/19/25 at 9:35 AM.

Diagnoses included type 2 diabetes with diabetic peripheral angiopathy with gangrene and chronic kidney disease, right leg below the knee amputation.

Resident D routinely leaves the facility for dialysis on Mondays, Wednesdays, and Fridays.A review of Resident D's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 14. (cognitively intact).

The MDS indicated the resident received insulin injections 5 days a week during the previous week of the assessment.A review of physician orders, dated 9/18/25-10/20/25, indicated blood glucose was to be measured four times a day.A review of physician orders, dated 9/18/25-10/6/25, indicated 18 units of insulin glargine was to be given once a day.

The order did not provide parameters to hold insulin or to hold on dialysis appointments.A review of physician orders, dated 10/6/25, indicated 18 units of Rezvoglar Kwik Pen insulin glargine was to be given once a day.

The order did not provide parameters to hold insulin or to hold on dialysis appointments.A review of the MAR, dated 10/1/25-10/31/25, indicated blood glucose was not documented as completed or refused on Sunday 8/5/25 at 8:00 AM, Tuesday 10/7/25 at 5:00 PM, and Tuesday 10/14/25 at 8:00 AM.

The 8:00 AM of 18 units of insulin glargine was held by facility staff, without physician parameters, on 10/6/25 for glucose of 120, 10/10/25 for a glucose of 93, 10/12/25 for a glucose of 132, 10/13/25 for a glucose of 121, 10/14/25 a note indicated the glucose was not measured prior to Resident D leaving the facility for a procedure, 10/22/25 a note indicated the resident was going to dialysis, 10/23/25 for a glucose of 124, 10/26/25 for a glucose of 100, 10/28/25 for a glucose of 95, and 10/30/25 for a glucose of 108.

The MAR indicated, 18 units Resvoglar insulin was routinely not given to Resident D on Mondays, Wednesdays, and Fridays (dialysis days), except for Monday 10/27/25 prior to dialysis. In an interview, on 11/19/25 at 3:02 PM, LPN 4 indicated staff routinely obtained a blood sugar measurement within an hour before meals and bedtime.

When insulin was required, within the parameters ordered, a Qualified Medical Assistant would need to have a nurse administer the insulin dose.

Documentation was required on the MAR.

When a resident was not in the building, staff would document the resident was not available or LOA.A current procedure, dated 2/2010, provided by the Administrator, indicated medications held or refused will be documented in the MAR.

Medication administration will be documented on the MAR after the medication has been given.

Insulin type, units to be given should be checked against the physician order at least 3 times for accuracy prior to administration.A current policy, dated 2/2003, provided by the Administrator, indicated staff was to administer medications and meals before or after dialysis as ordered.This citation is related to intake 2649663 and 2626035.3.1-30(a)

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