Health inspection·April 30, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interviews and record reviews, the facility failed to identify one of the three sampled residents (Resident 1) who had fluctuating Blood Sugar (BS) levels that were not reported to the Medical Doctor (MD). This deficient practice resulted in Resident 1 experiencing a hypoglycemic (a medical condition where the level of glucose (blood sugar) drops below the normal range (a normal fasting blood sugar range is typically 70 to 99 milligram per deciliter [mg/dL-unit of measurement]) incident with accompanying Altered Mental Status (AMS) on 1/22/2025. Findings: During a record review, Resident 1 ' s admission record indicated the facility admitted the resident on 1/15/2025, with diagnoses that included dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and Chronic kidney disease (CKD - a condition where the kidneys gradually lose their ability to filter waste products from the blood, leading to a buildup of toxins and other harmful substances in the body). During a record review, Resident 1 ' s physician ' s orders dated 1/19/2025 indicated the following: - Diet Order: Renal diet Texture: Soft bite sized* EXTRA GRAVY AND EXTRA DRINKS ON TRAY PLEASE*. Special Instructions: Licensed Nurse to monitor and verify diet Q week - Lantus Solostar (Glargine) U-100 Insulin (a hormone [chemical substance] produced by the pancreas [body organ] that regulates blood sugar levels by facilitating the entry of glucose into cells for energy) pen; 100 unit/ml (3 ml); amt: 18 units; subcutaneous (SQ- beneath, or under, all the layers of the skin) Special Instructions: Dx: DM. At Bedtime; 9 PM. - Insulin Aspart U-100 solution; 100 unit/ml; amt: 14 units; subcutaneous. Special Instructions: with breakfast. If eating 25-49 % of meal, Inject 7 units (measurement) only. Dx: DM Once A Day; 07:00 AM - insulin Aspart U-100 solution; 100 unit/ml; amt: 18 units; subcutaneous. Special Instructions: with lunch, If eating 25·49 % of meal, inject 9 units only, Dx: DM Once a Day; 12:00 PM Page 1 of 3 055540 055540 04/30/2025 Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404

F 0580 - insulin Aspart U-100 solution; 100 unit/ml; amt: 22 units; subcutaneous Level of Harm - Minimal harm or potential for actual harm - Special Instructions: with dinner. If eating 25-49 % of the meal, Inject 11 units only. Dx: DM. Once A Day; 05:00 PM Residents Affected - Few - 1/22/2025: Transferred Pt (Resident 1) to GACH (General acute care hospital) due to AMS (altered)/hypoglycemia. During a record review, Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 1/22/25, indicated Resident 1 had moderate cognitive impairment (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated Resident1 required between setup or clean-up and substantial/maximum assistance for eating, oral hygiene, toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. During a record review, Resident 1 ' s Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines who work together to provide comprehensive and coordinated patient care) care conference dated 1/21/2025 at 6:18 pm, indicated, [Resident 1] dietary Is anxious to go home and the meals which Is restricted CKD Mechanical Soft (a dietary modification designed for individuals who have difficulty chewing or swallowing certain foods) he [Resident 1] prefer regular diet, and he hasn't been eating that much. Therefore, I suggested to review what he would like, and he stated he rather go home. During a record review, Resident 1 ' s SBAR (Situation, Background, Assessment, Recommendation- is a verbal or written communication tool that helps provide essential, concise information) conference dated 1/22/2025 at 2:16 pm, indicated, [Resident 1] observed to be sleeping and not responding to verbal or physical stimuli. Blood sugar checked and the reading was 43 mg/dL. Glucagon injection administered and he began to respond, and his blood sugar gradually increased to 62 mg/dL. The Pt observed to be sleeping and not responding to verbal or physical stimuli. Blood sugar checked and the reading was 43 mg/dL. Glucagon injection administered and he began to respond, and his blood sugar gradually increased to 62 mg/dL. The SBAR indicated, that 911 (emergency telephone number in the United States and Canada used to call for immediate help from emergency services like police, fire, and ambulance) was called and Resident 1 was transported to GACH. During a record review, the GACH History and Physical (H&P- a comprehensive assessment of a patient, including a review of their medical history and a physical examination) dated 1/22/2025 indicated, Resident 1 presented from facility with AMS and hypoglycemia. The GACH H&P indicated staff at the facility noted Resident 1 to be altered and unresponsive with a BS level of 47 mg/dL and was sent the resident to GACH. During a concurrent interview and record review of Resident 1 ' s chart with the Director of Nursing (DON) on 04/13/2025 at 2:34 pm, the DON stated Resident 1 was sent to GACH due to low BS at 43mg/dl on 1/22/2025 at 11:15 am. The DON admitted and stated Resident 1's blood BS levels were out of whack and should have been addressed with the physician regarding the erratic BS levels which ranged between 83-to-328mg/dl. The DON acknowledged and stated that the resident's Medical Doctor (MD) should have been notified for further orders to prevent the very high and very low BS level. During an interview with Medical Doctor (MD) 1 on 04/13/25 at 5:13 pm, MD1 stated the facility 055540 Page 2 of 3 055540 04/30/2025 Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff must inform Resident 1 ' s MD about erratic BS levels so that insulin could be corrected via insulin sliding scale (a method used to determine the amount of insulin to administer based on a person's blood sugar level at a specific point in time). MD 1 stated Dietary consultation is indicated regarding the resident's BS levels. MD 1 stated Resident 1's erratic BS may have been avoided by notifying MD 1 who would then easily adjust the insulin dosages. During an interview with Licensed Vocational Nurse (LVN) 1 on 4/28/25 at 10:49 am, LVN 1 stated LVN 1 did not notify MD 1 about BS level because the levels appeared to be at baseline when LVN1 checked the resident's BS levels. LVN 1 admitted and stated BS trends must include levels from across all shifts to determine a true baseline and that a MD informed to prevent hypoglycemic or hyperglycemic (a medical condition where the level of glucose (blood sugar) rises above the normal range) episodes. During an interview with Registered Dietician (RD) on 4/28/25 at 11:15 am, the RD stated RD had visited with Resident 1. RD stated Resident 1 was supposed to be on a mechanical soft CKD diet, but the resident wanted to be on a regular texture diet. RD stated RD did inform Resident 1 that speech therapy staff are responsible in determining if Resident 1 could have regular diet after speech therapy evaluated Resident 1. RD admitted RD had not reviewed Resident 1 ' s BS level nor reviewed how much food Resident 1 was consuming. RD confirmed and stated Resident 1 ' s reduced meal intake could lead to a drop (hypoglycemia) in the BS. During a record review, the facility Policy and Procedure (P&P) titled, Changes in Resident Condition. revised 12/13/2024 indicated, The resident, attending Physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and direct care staff is also important to ensure that consistency and continuity of care are maintained. The same P&P indicated the procedure to inform attending physician when there is . a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 055540 Page 3 of 3