Health inspection·May 16, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews the facility failed to provide services that meet professional standards for one of three sampled residents (Resident 1), when Resident 1 was administered glucose gel (medical product used to treat low blood sugar levels) in his mouth while unresponsive and unable to follow directions. Residents Affected - Few The failure had the potential to cause Resident 1 to choke on or aspirate (accidental entry of food, liquid or other material into the lungs) the glucose gel. Findings: During a review of Resident 1 ' s admission record indicated, Resident 1 was admitted to the facility in February 2025, with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1 ' s care plan titled, Diabetes ., initiated on 2/20/25, indicated, .Resident has a diagnosis of diabetes and is at risk for complications . with goals including, .will minimize the risk for complication of diabetes to the extent possible . During an interview on 5/15/25 at 1:22 p.m., Paramedic 1 (PMD 1) stated he responded to a 911 call a for a hypoglycemic emergency on 4/26/25. PMD 1 stated upon arriving at the facility he observed Resident 1 unconscious with clear gel around his mouth and in his mouth, and with a blood glucose level measuring in the low 30s mg/dL (milligrams per deciliter, a unit of measure used for sugar in blood). The paramedic added, the nurse who was in the room with Resident 1, stated she gave Resident 1 glucose gel into his mouth, despite him being unconscious. The paramedic explained, giving glucose gel in the mouth while the resident was unconscious, created a choking or aspiration (accidental entry of food, liquid or other material into the lungs) risk. The paramedic stated, to be aligned with professional standards, he expected a glucagon injection (an emergency medicine used through syringe/need a to treat hypoglycemia for situations where someone cannot take glucose/sugar by mouth) should have been administered to Resident 1 while unconscious. An interview on 5/15/25 at 2:31 p.m., Resident 1 stated on 4/26/25 he had very low blood sugar, measured in the low 30s mg/dL, doesn ' t remember much about the emergency, but remembered waking up in the ambulance on the way to the hospital. An interview on 5/15/25 at 3:01 p.m., the Director of Nursing (DON) confirmed on 4/26/25 Resident 1 experienced a hypoglycemic emergency which rendered Resident 1 unconscious. The DON stated the Lead Nurse (LN 1) called 911 and Resident 1 was ultimately taken to the hospital for care related to his low blood sugar. Page 1 of 2 055268 055268 05/16/2025 Sonoma Post Acute 678 2nd Street West Sonoma, CA 95476

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 5/15/25 at 3:13 p.m., Licensed Nurse 1 (LN 1) stated she was the Lead Nurse on 4/26/25 when at approximately 10:30 a.m. she was alerted that Resident 1 was found unconscious. LN 1 confirmed Resident 1 was unresponsive . he could not follow commands . he did not respond to voice, and she gave Resident 1 glucose gel in the mouth to try to bring up his blood sugar. An interview on 5/15/25 at 3:47 p.m., LN 4 stated he has been trained when a resident is found unconscious or unresponsive in a hypoglycemic emergency, he would, give a glucagon needle shot . there is a glucagon needle shot in every medication cart . it ' s in the [facility ' s] policy. LN 4 added giving glucose gel in an unresponsive or unconscious resident ' s mouth would be a risk for aspiration or choking. A review of the facility ' s policy and procedure titled, Management of Hypoglycemia, revised March 2025, indicated, .To provide guidelines for managing hypoglycemia . in the diabetic resident .signs and symptoms of hypoglycemia .may include .(more severe) .unconsciousness . Level 3 hypoglycemia: altered mental and/or physical status requiring assistance for treatment . if a resident has Level 3 hypoglycemia and is unresponsive .administer 1 mg of glucagon subcutaneously [into the layer of tissue just beneath the skin] . 055268 Page 2 of 2