Health inspection·September 23, 2025

Health and Safety Code Section 1424 (d): Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 22 CCR § 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 22 CCR § 72513. Administrator. (a) Each skilled nursing facility shall employ or otherwise provide an administrator to carry out the policies of the licensee. (3) The administrator shall designate a responsible adult who is knowledgeable in the policies and procedures of the licensee in each facility to be responsible for carrying out the policies of the licensee in the administrator's absence. 22 CCR §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be implemented to ensure that patient-related goals and facility objectives are achieved. F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 5/20/25, the California Department of Public Health (Department) received a complaint that on 5/4/25 there was no nurse during 2 a.m. - 7 a.m. at the facility, during which diabetic residents did not receive blood glucose checks or insulin as prescribed. The Department determined during the investigation of the complaint, the facility failed to provide adequate care to five residents with the diagnosis of diabetes. The Facility failed to: 1. Administer medication as prescribed to Residents 2, 3, 4, 5, and 6 resulting in the five residents missing one or more administrations of prescribed insulin with dosage determined on a sliding scale based on blood sugar levels. 2. Monitor Residents 2, 3, 4, 5, and 6 blood sugar levels. 3. Ensure adequate staffing coverage to administer medication in a timely manner, resulting in the facility's failure to administer medication as prescribed. 4. Ensure adequate documentation of medication administration, as a result staff was uncertain whether prescribed dosages were missed. 5. Ensure timely consultation with a physician, resulting in a failure to get timely physician recommendations after possible missed dosages. 6. Ensure Residents 2, 3, 4, 5, and 6 care plan interventions were implemented. As a result of these failures, Residents 2, 3, 4, 5, and 6 missed blood glucose checks and insulin as prescribed by a treating physician, placing them at an increased risk of potentially life-threatening complications from diabetes. 1. Review of Resident 2's admission record indicated the resident was a 58-year-old female admitted to the facility on 5/14/24 with diagnoses including, diabetes mellitus type 2 (DM 2, a condition where your body either doesn't produce enough insulin, or your cells don't respond properly to insulin), hemiplegia and hemiparesis following cerebral infarction (a conditions that can occur after a stroke, leading to weakness or paralysis on one side of the body). During a review of Resident 2's "Physician Orders (PO)," dated 6/16/24, the "PO" indicated, to administer Novolin (Insulin) R (regular) injection solution 100 units/ml (milliliter), Regular inject as per sliding scale: 151 - 199 = 3 units; 201 - 249 = 4 units; 251 - 299 = 7 units; 301 - 349 = 10 units; 351 - 400 = 12 units; greater than 400 = 14 units of blood sugar/call doctor of medicine (MD). Subcutaneous (SQ, under the skin) per sliding scale every 6 hours for DM 2 management. During a review of Resident 2's "Medication Administration Record (MAR)," dated 5/4/25, the "MAR" indicated, there was no documentation of insulin administration or blood sugar levels for the 6 a.m., morning dose. There was also no nursing progress note explaining the omission or indicating the physician was notified of the failure to administer insulin. During a review of Resident 2's "Care Plan (CP)," dated 11/26/24, the "CP" indicated Resident 2 had Diabetic Medication. The CP interventions included: "Administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness." 2. Review of Resident 3's admission record indicated the resident was an 84-year-old female admitted to the facility on 6/18/20 with diagnoses including, DM 2 and heart failure. During a review of Resident 3's "PO," dated 6/16/24, the "PO" indicated, to administer Novolin R injection solution 100 unit/ml, Regular inject as per sliding scale: 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 7 units; 301 - 350 = 9 units; 351 - 400 = 11 units; >400 = 13 units, SQ, before meals and at bedtime for DM 2. Call MD if blood sugar above 400 or below 70. During a review of Resident 3's "MAR," dated 5/4/25, the "MAR" indicated, there was no documentation of insulin administration or blood sugar levels for the 6:30 a.m., morning dose. There was also no nursing progress note explaining the omission or indicating the physician was notified of the failure to administer insulin. During a review of Resident 3's "CP," dated 10/14/24, the "CP" indicated, Resident 3 had DM 2 manifested by hyperglycemia/hypoglycemia (low/high blood sugar) episodes. The CP interventions included, "Administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness Notify MD prn (as needed)." 3. Review of Resident 4's admission record indicated the resident was a 96-year-old male admitted to the facility on 1/31/25 with diagnoses including, DM 2 and chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 4's "PO," dated 2/1/25, the "PO" indicated, to administer Insulin Lispro solution 100 unit/ml, Regular inject as per sliding scale: 151 - 199 = 1 units; 201 - 249 = 2 units; 251 - 299 = 3 units; 301 - 349 = 4 units; SQ, before meals and at bedtime for DM 2. Blood sugar less than 60 or greater than 400, call MD. During a review of Resident 4's "MAR," dated 5/4/25, the "MAR" indicated, there was no documentation of insulin administration or blood sugar levels for the 6:30 a.m., morning dose. There was also no nursing progress note explaining the omission or indicating the physician was notified of the failure to administer insulin. During a review of Resident 4's "CP" dated 10/14/25, the "CP" indicated, Resident 4 has DM medication. The CP interventions included: "Administer medication as ordered ... obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated." 4. Review of Resident 5's admission record indicated the resident was a 74-year-old female admitted to the facility on 4/22/25 with diagnoses including, DM 2 and left tibia fracture (a broken left shinbone). During a review of Resident 5's "PO," dated 2/1/25, the "PO" indicated, to administer Insulin Regular solution 100 unit/ml, Regular inject as per sliding scale: 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; >400 = 12 units, and call MD. SQ, before meals and at bedtime for DM 2. During a review of Resident 5's "MAR," dated 5/4/25, the "MAR" indicated, there was no documentation of insulin administration or blood sugar levels for the 6:30 a.m., morning dose. There was also no nursing progress note explaining the omission or indicating the physician was notified of the failure to administer insulin. During a review of Resident 5's "CP," dated 4/23/25, the "CP" indicated, Resident 5 has DM medication. The CP interventions included, "Administer medication as ordered. Monitor for signs and symptoms of hyperglycemia such as ..." 5. Review of Resident 6's admission record indicated the resident was a 64-year-old male admitted to the facility on 4/22/25 with diagnoses including, DM 2 and osteomyelitis (a bone infection, usually caused by bacteria). During a review of Resident 6's "PO," dated 2/1/25, the "PO" indicated, to administer Insulin Lispro solution 100 unit/ml, Regular inject as per sliding scale: 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; >400 = 10 units, SQ, before meals and at bedtime for DM 2. During a review of Resident 6's "MAR," dated 5/4/25, the "MAR" indicated, there was no documentation of insulin administration or blood sugar levels for the 6:30 a.m., morning dose. There was also no nursing progress note explaining the omission or indicating the physician was notified of the failure to administer insulin. During a review of Resident 6's "CP," dated 2/7/25, the "CP" indicated, Resident 6 had potential for hyperglycemia/hypoglycemia related to diagnosis of DM. The CP interventions included, "Insulin Lispro Inject solution 100 unit/ml. inject as per sliding scale ... monitor blood sugar levels as ordered." During an interview on 6/2/25 at 5:45 p.m. with Licensed Nurse (LN 4), LN 4 stated that on 5/3/25, the licensed staff scheduled to work the overnight shift from 11 p.m. - 7 a.m. called out, indicating they were not able to work the 11 p.m. - 7 a.m. shift on 5/3/25. LN 4 stated the nurses from the afternoon (3 p.m. - 11 p.m.) shift stayed until 2 a.m. per administrator approval. LN 4 confirmed there was no licensed nurse assigned to the skilled unit (Residents 2, 3, 4, 5, and 6's unit) from 2 a.m. until 7 a.m. on 5/4/25. LN 4 further stated the scheduled 5 a.m. - 6:30 a.m. medications were not administered to residents during that time. Review of the staffing schedules indicated on 5/4/25 from 2 a.m. until 7 a.m. there were four Certified Nursing Assistant (CNAs) on the skilled unit, but no licensed nurses. The subacute unit had two CNAs, one Licensed Vocational Nurse and one Registered Nurse. During an interview on 6/30/25 at 11 a.m., with the Interim Director of Nursing (IDON), IDON acknowledged that the MARs for all five residents were left blank on 5/4/25 for 6:30 a.m. and confirmed they should not have been left blank. She stated that if the insulin was not administered and blood glucose was not monitored, staff should have documented the reason in the nursing progress notes. During a review of the facility's policy and procedure (P&P) titled, "Care Plans, Comprehensive Person-Centered," dated 12/2016, the P&P indicated, "The comprehensive, person-centered care plan will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being." During a review of the facility's P&P titled, "Administering Medication," dated April 2019, the P&P indicated, "Medications are administered in a safe and timely manner, and as prescribed ... Medications are administered in accordance with prescribe orders, including any required time frame." During a review of the facility's P&P titled, "Adverse Consequences and Medication Errors," dated April 2014, the P&P indicated, "Examples of medication errors include: a. omission - a drug was ordered but not administered." During a review of the facility's P&P titled, "Charting and Documentation," dated 4/2008, the P&P indicated, "Policy Statement - All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record." The facility failed to: 1. Administer medication as prescribed to Residents 2, 3, 4, 5, and 6, resulting in the five residents missing one or more administrations of prescribed insulin with dosage determined on a sliding scale based on blood sugar levels. 2. Monitor Residents 2, 3, 4, 5, and 6 blood sugar levels. 3. Ensure adequate staffing coverage to administer medication in a timely manner, resulting in the facility's failure to administer medication as prescribed. 4. Ensure adequate documentation of medication administration, as a result staff was uncertain whether prescribed dosages were missed. 5. Ensure timely consultation with a physician, resulting in a failure to get timely physician recommendations after possible missed dosages. 6. Ensure Residents 2, 3, 4, 5, and 6's care plan interventions were implemented. As a result of these failures, Residents 2, 3, 4, 5, and 6 missed blood glucose checks and insulin as prescribed by a treating physician, placing them at an increased risk of potentially life-threatening complications from diabetes. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.