Rolling Hills Healthcare Center

F-F842

3.1-37

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 155488 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155488 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare Center 3625 St Joseph Rd New Albany, IN 47150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 51675 potential for actual harm Based on observation, interview and record review the facility failed to ensure interventions and treatments Residents Affected - Few were completed for 1 of 4 residents reviewed for pressure ulcers. (Resident 53).

Findings included:

The record for Resident 53 was reviewed on 5/7/25 at 12:29 p.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus, morbid obesity, osteomyelitis of vertebra, sacral and sacrococcygeal region, and chronic embolism and thrombosis.

A physician's order, dated 1/13/25, indicated staff were to obtain the resident vitals every shift for 72 hours and then daily to establish baselines.

The record lacked documentation to indicate the resident's vital signs were being completed.

The last recorded blood pressure was on 1/28/25 at 95/66 (mm/hg) millimeters of mercury. Vital sign monitoring was an intervention in the care plans of actual skin impairment and osteomyelitis.

The care plan, dated 1/14/25, indicated the resident had actual impaired skin integrity that included, a Stage 4 pressure ulcer to the sacrum and unstageable wound to right hip. On 3/17/25, the area to the right hip was classified as stage 4 pressure ulcer. The interventions included, but were not limited to, low air loss mattress to bed per manufacturer guidelines, monitor the area for signs of infection, monitor the area for signs of progression, encourage turning and repositioning, and provide wound care per treatment orders.

The Wound Assessment report, dated 1/14/25, indicated the resident had a stage 4 pressure injury to the sacrum, measuring 5 cm (centimeters) in length, by 2 cm in width by 3 cm in depth with serosanguineous drainage with subcutaneous tissue, bone and adipose tissue present. The wound was not acquired in house.

The treatment was to cleanse the wound with NS (Normal Saline) cleanser, then apply NS wet to moist rolled gauze to the wound bed, and cover with a bordered gauze dressing every 12 hours and as needed until resolved

On 2/4/25, the wound assessment indicated the sacrum wound measured 5 cm in length, by 1 cm in width by 2.7 cm in depth.

On 3/6/25, the wound assessment indicated the wound measured 4.8 cm in length, by 1 cm in width, by 2 cm

in depth.

On 4/22/25, the wound assessment indicate wound measured 4.6 cm in length, by 1.2 cm in width by 2 cm in depth. The resident was on antibiotics to treat a wound infection, and the status indicated the wound was improving with complications.

On 5/6/25, the wound assessment indicated the wound measured 4.5 cm in length, by 1.2 cm in width by 2 cm in depth.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 155488 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155488 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare Center 3625 St Joseph Rd New Albany, IN 47150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 A physician's order, dated 1/14/25, indicated that a low air loss mattress should be applied, which should be checked every shift for proper placement and function. Level of Harm - Minimal harm or potential for actual harm The care plan, dated 1/22/25, indicated that the resident had a history of osteomyelitis. The interventions included, but were not limited to, observe the resident for any signs of infection, monitoring of vital signs, and Residents Affected - Few administer antibiotics per the medical provider's orders.

A nurse's note, dated 2/28/25, indicated during wound care on the sacrum the resident alerted the nurse that

a previously scabbed area to the side of her right thigh was bothering her. The nurse observed the right thigh had an open area with a small amount of drainage. The nurse notified the provider and received an order for wound care. The resident was encouraged not to sit in her wheelchair as frequently to promote healing of both wounds.

The Wound Assessment report, dated 3/6/25, indicated the resident had an unstageable pressure injury to

the right hip, measuring 3 cm in length, by 2.5 cm in width by 0.1 cm in depth with no drainage and subcutaneous tissue exposed. The wound was in house acquired. Treatment included to cleanse the wound with NS cleanser, apply medical grade honey to the wound bed, and cover with a bordered gauze dressing until resolved daily and as needed.

On 3/13/25, the wound assessment indicated the resident had an unstageable pressure injury to the right hip, measuring 2.8 cm in length, by 2.2 cm in width by 0.1 cm in depth with no drainage and subcutaneous tissue was exposed.

On 4/1/25, the wound assessment indicated that the resident had a Stage 3 pressure injury to the right hip, measured 2 cm in length, by 1.7 cm in width by 2.4 cm in depth with a moderate amount of serosanguineous drainage and subcutaneous tissue and the dermis were exposed.

On 4/22/25, the wound assessment indicated the resident had a Stage 3 pressure injury to the right hip measured 1.1 cm in length, by 1.6 cm in width by 2.4 cm in depth with a moderate amount of serosanguineous drainage and subcutaneous tissue and dermis were exposed.

On 5/6/25, the wound assessment indicated the resident had a Stage 3 pressure injury to the right hip measured 1.1 cm in length, by 1.6 cm in width by 1.7 cm in depth with a moderate amount of serosanguineous drainage and subcutaneous tissue and dermis were exposed. The peri-wound was intact, but fragile.

A skin note, dated 3/6/25, indicated that the resident was seen for wound rounds. The sacrum was stable at that time. The wound to the right hip was noted to be a pressure ulcer. The area was suspected of being caused by the resident's previous wheelchair, and the wheelchair had been replaced.

A physician's order, dated 3/6/25, indicated to cleanse the area to the side of the right thigh with wound cleanser and pat dry. The order read to apply silver collagen to the wound bed and place saline wet to moist gauze over the wound and cover it with a dry dressing daily and as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 155488 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155488 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare Center 3625 St Joseph Rd New Albany, IN 47150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 A nurse's note, dated 4/2/25, indicated that during a dressing change the nurse observed the wound to resident's sacrum had green drainage along with a very strong foul odor. Neither drainage or odor was Level of Harm - Minimal harm or documentated previously during the dressing changes. The NP was notified and gave orders for Doxycycline potential for actual harm 100 mg twice daily for 7 days, probiotic twice daily for 10 days and for a wound culture to be obtained on next dressing change. Residents Affected - Few

A nurse's note, dated 4/7/25, the resident was seen by the wound care center. The wound center obtained a wound culture during the visit. The nurse then called the wound center to notify the physician that the resident was currently on an antibiotic for wound infection.

A nurse's note, dated 4/14/25, indicated the wound center ordered amoxicillin for 10 days and for the resident to return to the wound center on 4/28/25.

A nurse's note, dated 4/22/25, indicated that the resident had refused further use the low air loss mattress, and the resident was encouraged to turn and reposition while in bed. The intervention was not removed from

the resident care plans. The May 25 (EMAR/ETAR) Electronic Administration Record/Electronic Treatment Administration Record indicated that the order was still on the EMAR/ETAR and was to be checked every shift for proper placement and function. This was completed by nursing staff every shift despite the removal of the mattress on 4/22/25.

A physician's order, dated 4/29/25, indicated to cleanse the area to the sacrum with wound cleanser and pat dry, apply silver collagen to the wound bed, place a fluffed normal saline, wringing out the excess saline, collagen in place, and cover the area with a bordered gauze daily for wound care.

The April and May 25 EMAR/ETAR indicated the resident record lacked documentation of the daily wound assessment to the right thigh wound on 4/7/25, 4/11/25, 4/23/25, 5/2/25, and 5/3/25.

The record lacked documentation of wound care and dressing changes on the right thigh on 4/9/25 and 5/2/25.

The record lacked docunentation of wound care and dressing changes to the sacrum on 4/9/25, 4/28/25, and 5/2/25.

The record lacked documentation of a daily assessments to the sacral wound on 5/2/29.

The Braden Assessment scores completed for the resident included a low-risk score for skin breakdown 1/27/25, 2/3/25, and 5/4/25.

For the month of May 2025, the resident consistently rated her pain at 4 to 5 out of 10. The pain scale indicated 10 being severe. The resident received pain medication twice daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 155488 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155488 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare Center 3625 St Joseph Rd New Albany, IN 47150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an observation, 5/8/25 at 10:00 a.m., Licensed Practical Nurse (LPN) 10 performed hand hygiene.

The resident stood up with assistance and bent over the chair for completion of the wound care. The right hip Level of Harm - Minimal harm or wound had redness on the tissue surrounding the wound, The wound was tunneling with a small amount of potential for actual harm slough and a moderate amount of serosanguineous exudate. The wound was cleaned with wound cleanser, packed with prism collagen, a wrung out 4 x 4 was placed on top of the wound and covered with bordered Residents Affected - Few gauze. The nurse removed her gloves and performed hand hygiene. The nurse completed wound care to the sacrum. A dressing was then removed, cleaned with wound cleanser, packed the prism collagen and packed

a normal saline soaked gauze. The wound was then covered with bordered gauze. Neither dressing to the right hip or sacrum was dated.

During an interview, 5/8/25 at 10:15 a.m., the resident indicated that she does not have any pain due to having routine pain medication. She had a pressure cushion on the wheelchair. The pressure reducing mattress was removed due to the resident was not comfortable on the mattress. She went to bed 2 to 3 times per day, and turned and repositioned herself while in bed. She reported that she was finished with the antibiotics for a sacrum wound infection.

During an interview, on 5/8/25 at 10:20 a.m., LPN 10 indicated the resident was not comfortable on the air loss mattress, so it was removed. The resident did have an air loss cushion on her wheelchair. The resident was good at turning and repositioning herself every 2 hours while in bed. If a resident refused any intervention, the physician or the NP would be notified.

A wound care policy was not received from the facility.

3.1-40

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 155488 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155488 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare Center 3625 St Joseph Rd New Albany, IN 47150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34309

Residents Affected - Some Based on observation, record review, and interview, the facility failed to ensure the food was disposed of once expired, the vents were cleaned and repaired, the refrigerator thermostat and drip pan under the stove top were repaired. This had the potential to affect 93 of 95 residents who consume meals from the facility.

Findings include:

During the initial tour of the kitchen on [DATE REDACTED] at 9:10 a.m., the following concerns were observed:

- On a stand-alone refrigerator, the external temperature was at 38 degrees Fahrenheit (F). No internal thermometer was located. A gallon container of whole milk, which was ,d+[DATE REDACTED] full, had an expiration date of [DATE REDACTED].

- The second stand-alone refrigerator, had an external temperature of 37 degrees F. No internal thermometer was located. There was a container of leftover fish, with a use by date of [DATE REDACTED]. There was another container of tuna, with a use by date of [DATE REDACTED]. There was a container of lettuce with brown edges, but no serve date or use by date.

- The third stand-alone refrigerator, the external temperature read 50 degrees F. There was no internal thermometer. There were 16 prepared glasses of cranberry juice and lemonade on the trays. There were 9 glasses of lemonade and tea on the other side of the stand-alone refrigerator. There were 5 pitchers of orange juice, tea, lemonade, water and cranberry juice, which were half full. [NAME] 3 indicated the drinks were still in use.

- Dust was observed on the two vents over the serving counter. The vent over the preparation table had 3 screws holding the vent to the ceiling. The fourth corner of the vent was hanging loose. [NAME] 3 indicated when it rained, the vent would hang down.

- The Dietary Manager was observed placing a tray of dessert bars into the trash can from the freezer. The same dessert bars were also on a tray in the stand-alone refrigerator with no date.

- One of the 3 drip pans under the cook top had a drip pan stuck with food debris and grease build up, almost up to the underside of the cook top panel, visible through the opening of the pan.

The review of the Menu, indicated the fish had last been served on [DATE REDACTED] for dinner and [DATE REDACTED] for lunch.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 155488 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155488 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare Center 3625 St Joseph Rd New Albany, IN 47150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a second kitchen observation, on [DATE REDACTED] at 10:45 a.m., the instant mashed potatoes were being prepared. [NAME] 3 obtained the gallon container of whole milk, which was ,d+[DATE REDACTED] full, with a use by Level of Harm - Minimal harm or date of [DATE REDACTED], and began pouring it into the instant mashed potatoes. When asked about the date, [NAME] potential for actual harm 3 stopped pouring, checked the date and indicated the milk was bad and that it was her fault that she hadn't looked at the use by date. She thought she had grabbed the whole milk with the use by date of [DATE REDACTED]. She Residents Affected - Some would discard the mashed potatoes and she took it away. [NAME] 3 indicated that the gallon containers were used for cooking and the small containers were for the residents to drink.

During a third observation in the kitchen, on [DATE REDACTED] at 9:18 a.m., the same fish in the container had been re-dated to read a serve date of [DATE REDACTED] and use by date of [DATE REDACTED]. The vent over the serving table still had

a coating of dust. The vent over the preparation table was still pulled away from the ceiling. The lettuce with

the brown edges had been removed from the refrigerator. The tuna in a container had been removed.

During an interview, on [DATE REDACTED] at 9:19 a.m., the Dietary Regional Director of Operation (RDCO) indicated

the fish would have been on the menu, on Friday, [DATE REDACTED]. The Dietary RDCO checked the refrigerators bi-weekly for expired dates.

During an interview, on [DATE REDACTED] at 9:24 a.m., the Dietary Manager indicated she was responsible for monitoring the expiration dates on food items, but all staff should monitor the dates. The Maintenance Director was responsible for cleaning the vents and doing repairs in the kitchen, such as repairing the drip pan and the vent being attached to the ceiling.

The current Food Storage and Retention Guide, included, but was not limited to, . Raw Meat/Poultry/Seafood Fish, seafood, ground meat and all poultry Once thawed ,d+[DATE REDACTED] days .

The current Labeling and Dating Inservice, included, but was not limited to, . Purpose: To educate all new hires and current employees on the importance of and guidelines for proper labeling and dating . Guidelines for Labeling and Dating . The use by date as outlined in the attached guidelines . Leftovers must be labeled and dated with the date they are prepared and the use by date .

The Maintenance Supervisor Position Description, dated [DATE REDACTED], included, but was not limited to, . Plan, develop and schedule preventive maintenance for the center. Establish standards for preventive maintenance and cleaning .

3XXX,d+[DATE REDACTED](i)(3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 155488 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155488 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare Center 3625 St Joseph Rd New Albany, IN 47150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 35732

Residents Affected - Few Based on record review and interview, the facility failed to ensure sufficient information related to a resident's blood sugar was rechecked; and physician notification and verbal orders were documented in the resident's clinical record for 1 of 21 residents reviewed for Documentation. (Resident 243)

Findings include:

The record for Resident 243 was reviewed on 5/5/25 at 11:17 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, and sepsis due to methicillin susceptible staphylococcus aureus, and hyperglycemia.

The physician's order, dated 4/9/25, indicated the resident was to receive Lispro 100 units per mg before meals for diabeties. The staff were to administer the rsident's insulin based on a sliding scale. The staff were to notifiy the physician if the resident's blood surgar level was less the 70 or grater than 400. If the resident's blood sugar level was 151 to 200 staff were to administer 2 units; 201 to 250 administer 4 units; 251 to 300 administer 6 units; 301 to 350 administer 8 units; 351 to 400 administer 10 units, and if the resident's blood sugar was greater than 400 administer 10 units, then recheck the resident's blood sugar in 30 minutes, and notify the physician.

The review of the residents' blood sugar indicated the following:

- On 4/30/25 at 10:38 a.m., the residents' blood sugar was 400.0 mg/dL(milligrams/deciliters)

- On 4/30/25 at 4:59 p.m., the residents' blood sugar was 502.0 mg/dL

- On 4/30/25 at 5:31 p.m., the residents' blood sugar was 502.0 mg/dL

- On 5/1/25 at 7:41 a.m., the residents' blood sugar was 430.0 mg/dL

- On 5/1/25 at 9:13 a.m., the residents' blood sugar was 494.0 mg/dL

- On 5/1/25 at 9:28 a.m., the residents' blood sugar was 494.0 mg/dL

- On 5/1/25 at 12:06 p.m., the residents' blood sugar was 277.0 mg/dL

- On 5/1/25 at 3:10 p.m., the resident's blood sugar was 400.0 mg/dL

The nurse's note, dated 4/30/25, at 4:59 p.m., indicated the physician was called for a blood sugar of 502 mg/dL.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 155488 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155488 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare Center 3625 St Joseph Rd New Albany, IN 47150

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The nurse's note, dated 4/30/25, at 5:31 p.m., indicated the resident's blood sugar was 502 mg/dL at dinner time. The nurse tried to call the physician and left a message. The resident's blood sugar had been high all Level of Harm - Minimal harm or day. The nurse called the Director of Nursing (DON) and documented she was told by the DON to give 10 potential for actual harm units of the sliding scale insulin and recheck the blood sugar in 30 minutes.

Residents Affected - Few The record lacked documentation indicating the physiucian/Nurse Practitioner (NP) received the left message, a recheck of the resident's blood sugar was completed, or any verbal NP orders were received.

During an interview, on 5/7/25 at 9:55 a.m., RN 8 indicated the resident's blood sugar was 502 mg/dL and

she tried to call the physician without success. She called the DON and was told to call the NP on call because she would probably order 10 units of insulin. She indicated she took a verbal order from the NP to give the insulin. The RN was unable to locate a verbal order from the NP in the resident's medical record.

During an interview, on 5/7/25 at 10:15 a.m., the Regional Director of Clinical Operations (RDCO) indicated

the DON told the RN to give the 10 units of the sliding scale insulin and call the NP. She indicated she had talked to the NP this morning and the NP indicated she was made aware of the resident's high blood sugars.

The RDCO agreed that the record lacked documentation the NP was notified, and the blood sugar was rechecked.

During an interview, on 5/7/25 at 10:25 a.m., the DON indicated the RN called her and she instructed her to give the 10 units according to the sliding scale and call the NP. She indicated the night shift nurse called her later and told her the resident's blood sugar was down to 300 mg/dL.

During an interview, on 5/8/25 at 8:37 a.m., NP indicated she was made aware the resident's blood sugars were high. She added a note on 5/1/25 that indicated she increased the resident's insulin. The NP indicated

on 5/7/25 she called the pharmacy and requested the resident's Intravenous (IV) antibiotics be mixed with normal saline instead of dextrose (sugar).

During an interview, on 5/8/25 at 8:50 a.m., the RDCO indicated the nurse had given the 10 units according to the sliding scale and his blood sugar came down to 300 mg/dL. She indicated there should have been documentation the nurse called the NP and documented the blood sugar and what time it was taken.

The clinical documentation standards policy dated 2014, included, but was not limited to, .a. The primary purpose of the medical record (s) is to provide continuity of care 1. Clinical evidence of care and treatment records as evidence of care iv. Document the status of the resident including changes i. The medical record will reflect the current status of the resident a. Chart in [real time] when an event is occurring or shortly thereafter, as is practicable .

3.1-3(o)(r)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 155488