Health inspection·August 21, 2025

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 Based on interview and record review, the facility failed to provide necessary care and services to one of three sampled residents (Resident 1) by failing to:A. Ensure Resident 1's physician's orders were followed when Licensed Vocational Nurse 1 (LVN 1) held administration of Tresiba (a once-daily medication used to manage high blood sugar).B. Ensure accurate medication administration documentation for Resident 1, when LVN 2 did not document the Tresiba administration for Resident 1 on 8/9/2025.These deficient practices had the potential to result in serious health complications for Resident 1.Findings:A. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 11/4/2018 and readmitted the resident on 8/12/2025 with a diagnosis including type 2 diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) and unspecified hypoglycemia (body's blood sugar level goes below the standard range).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/25/2025, the MDS indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were intact.During a review of Resident 1's Order Summary Report (OSR) dated 7/1/2025, the OSR indicated Resident 1 had an order for Tresiba 55 units (a unit of measurement) subcutaneous injection (a method of delivering medication into the fatty tissue layer located just beneath the skin) in the morning related to type 2 diabetes mellitus with a start date of 4/23/2025.During review of Resident 1's Medication Administration Record (MAR) dated 7/1/2025 -7/31/2025 and 8/1/2025 - 8/31/2025, the MAR indicated the 6:30 AM dose for Tresiba 55-unit[s] subcutaneous injection was held on 7/11/2025, 7/12/2025, 7/18/2025, 7/23/2025, 7/29/2025, 7/30/2025, 8/2/2025, and 8/6/2025 by LVN 1.During a review of Resident 1's Care Plan (CP) titled (Resident 1) has diabetes mellitus, initiated 4/29/2025, revised 8/13/2025, cancelled 8/13/2025, the CP's goal indicated Resident 1 will have no complications related to diabetes. The CP's interventions indicated for licensed nursing staff to administer diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness.During a telephone interview on 8/20/2025 at 3:44 PM with LVN 1, LVN 1 stated LVN 1 would hold Resident 1's 6:30 AM dose of Tresiba 55 units if Resident 1's blood sugar level was below 170 milligrams per deciliter (mg/dL-a unit of measurement). LVN 1 stated Resident 1's Tresiba order did not indicate the Tresiba should be held if Resident 1's blood sugar was below 170 mg/dL. LVN 1 stated LVN 1 notified the Registered Nurse Supervisor (RN1) that LVN 1 held the Tresiba medication.During a telephone interview on 8/20/2025 at 4:30 PM with RN 1, RN 1 stated LVN 1 informed RN 1 that LVN 1 held the Tresiba Medication for Resident 1. RN 1 stated the doctor was not notified when Resident 1's Tresiba was held.During an interview on 8/21/2025 at 12:25 PM with the Director of Nursing (DON), the DON stated if a physician's order does not indicate a medication was to be held, it was the facility's policy to get a doctor's order prior to holding the medication.B. During an interview on 8/20/2025 at 12:53 PM with Resident 1, Resident 1 stated on the morning of 8/9/2025 Residents Affected - Some Page 1 of 2 055141 055141 08/21/2025 Madera Post Acute Center 11900 Ramona Boulevard El Monte, CA 91732

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN 2 administered Tresiba 55 units to Resident 1.During a telephone interview on 8/20/2025 at 3:37 PM with LVN 2, LVN 2 stated on 8/9/2025 at 5:40 AM, LVN 2 administered Tresiba 55 units to Resident 1.During a concurrent interview and record review on 8/21/2025 at 12:25 PM with the DON, Resident 1's MAR dated 8/1/2025-8/31/2025 was reviewed. The MAR indicated the 8/9/2025 6:30 AM dose for Tresiba 55-unit[s] subcutaneous injection was not administered. The DON stated LVN 2 should have documented the 6:30 AM dose of Tresiba administered by LVN 2 on 8/9/2025 in Resident 1's MAR.During a review of the facility's undated Policy and Procedure (P&P) titled, Medication Administration, the P&P indicated, medications will be administered as prescribed by the physician. The P&P's administration process indicated that the person administering the medication is to initial the resident's medication sheet in the provided space under the appropriate date and time for that particular dose administered. The P&P's administration process indicated, documentation on the medication sheet is done immediately following administration. 055141 Page 2 of 2