Health inspection·October 9, 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 interview, and record review, the facility failed to follow their policy and procedure (P&P) when it did not administer regular insulin (a medication that helps your body use sugar for energy) that was readily available in their emergency kit (e-kit- small quantity of medications that can be dispensed when pharmacy services are not available) and instead used the insulin brought to the facility by resident's family. Residents Affected - Few This had the potential to administer a medication that could have been tampered, contaminated or unsafe for use for one of three sampled residents (Resident 1). Findings: During an interview on October 9, 2023 at 10:53 AM with Resident 1 inside his room, Resident 1 stated he was admitted on [DATE] and did not receive his insulin dose when he first came in. A review of Resident 1's admission Record , indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (DM- commonly referred as diabetes, a health condition that affects how your body turns food into energy) among others. A review of Resident 1's History and Physical (a brief documentation of a resident's medical condition) , dated October 2, 2023, indicated Resident 1 has the capacity to understand and make decisions. During a concurrent interview and record review on October 9, 2023 at 11:53 AM with the Director Of Nursing (DON), Resident 1's SBAR/COC Assessment Form (SBAR- a written communication tool that helps provide essential, concise information, usually during a change of condition [COC]), dated September 30,2023, at 2:30 PM was reviewed. The DON stated that per SBAR/COC, Resident 1 had a blood sugar (concentration of sugar in the blood, with normal range of 70 to 100 milligram per deciliter [mg/dl- a unit of measurement]) of 506 mg/dl. Further review of the associated Licensed Progress Notes indicated Resident 1's doctor was made aware with order for 20 units of insulin. During an interview on October 12, 2023 at 2:08 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was helping out LVN 1 in taking care of Resident 1 on September 30, 2023. LVN 2 stated she checked Resident 1's blood sugar at 506 mg/dl and notified the doctor. LVN 2 stated she also notified the doctor that Resident 1's medications hasn't been delivered yet by pharmacy, and that Resident 1's wife was insisting on administering Resident 1's regular insulin brought in from home by Resident 1's wife. LVN 2 stated there was regular insulin in the facility e-kit, but she administered the regular insulin brought in by Resident 1's wife after getting approval from the doctor and the DON. Page 1 of 2 055076 055076 10/09/2023 Spring Valley Post Acute LLC 14973 Hesperia Rd Victorville, CA 92395

F 0684 LVN 2 stated she should have given the regular insulin from the e-kit. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on October 12, 2023, at 2:49 PM with the DON, Resident 1's Physician's Telephone Orders , dated September 30, 2023, at 2:30 PM was reviewed. The order indicated, Give 20 units regular insulin x 1 dose . The DON stated there was nothing in the order that indicated the regular insulin could be taken from the home medication brought in by Resident 1's wife. The DON further stated the regular insulin administered to Resident 1 should have been taken from the e-kit. Residents Affected - Few During a concurrent interview and record review on October 16, 2023 at 9:12 AM, with the DON, the facility's P&P titled, Medications Brought to the Facility by the Resident/Family , effective October 2015 was reviewed. The P&P indicated, .The facility shall ordinarily not permit residents and families to bring medications into the facility .2. The facility discourages the use of medications brought in from outside, and will inform residents and families of that policy as well as applicable laws and regulations .3. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services/RN Supervisor shall check to ensure that: a. State law and regulations allow such use; b. The medications have been ordered by the resident's Attending Physician, and documented on the physician's order sheet; c. The contents of each container are labeled in accordance with established policies . The DON stated the physician's order dated September 30, 2023 at 2:30 PM did not indicate that the insulin can be taken from home meds brought in by Resident 1's wife. The DON stated the regular insulin was available and should have been taken from the facility e-kit. The DON further stated the facility did not follow their policy and procedure. 055076 Page 2 of 2