Inspection·January 27, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doctor. There were some high blood sugar results like 380 and it was more consistently high. It was 230 at some points and sugar checks are early in the morning at 6:30 a.m. Resident 1 was admitted for respiratory, maybe the flu. During a review of Resident 1's Progress Note, dated 1/14/25, by the Physician Assistant, the Progress Note indicated, This is an [AGE] year-old gentleman with significant past medical history of coronary artery disease with diastolic dysfunction, COPD, and multiple other medical issues who was admitted for shortness of breath. Patient was found to have COPD exacerbation with upper respiratory infection with rhinovirus. Medically, patient was treated and subsequently was sent here for further rehabilitation. The only mention of Resident 1 having DM2 is under the heading Current Medications, Glucose gel. Under Assessment/Plan there is no mention of a plan for Resident 1's DM2. The only mention of Resident 1 having DM2 is under the heading Current Medications, Glucose gel. Under Assessment/Plan there is no mention of a plan for Resident 1's DM2. During a review of Resident 1's Progress Notes, dated 1/15/25, the Progress Note indicated, Dr. (name) was notified at approximately 0550 because the resident ' s finger stick was HI. It was taken twice. Dr. (name) said to give him 10 units of Lispro and recheck in one hour. At approximately 0715 the finger stick was retaken and it still read out HI. Message left with Dr. The AM nurse was told about this resident ' s finger sticks and the insulin was given. She was told that the fingerstick was retaken and it read out HI. There was no order written or signed by the physician for the 10 units of Lispro. There were no further progress notes regarding Resident 1's glucose until 1/17/25. Resident 1's blood glucose level was documented on the MAR on 1/16/25 as 388. During a concurrent interview and record review on 1/27/25 at 1:05 p.m. with Licensed Nurse (LN 1) Resident 1's Medication Administration Record (MAR) was reviewed and indicated, blood sugar checks began on 1/9/25 with a result of 144 fasting. LN 1 further verbalized Resident 1's blood sugar kept getting higher, it was 252 the next day then 385 and the next day 390. Our standard is to notify the doctor if it is above 400. The night shift nurse notified the doctor on 1/15/25 at 5:58 a.m. and the order received from the doctor was to give 10 units of Lispro and check in one hour, then it was checked at 7:15 a.m. and it was reading HI and that was during shift change and Resident 1 was endorsed to the next nurse. LN 1 verbalized there was no further documentation about blood sugars until 1/17/25 when Resident 1's blood sugar had another high result and that is when they sent Resident 1 out. During a review of Resident 1's Health Status Note, created 1/25/25, the Note indicated Late entry, This note is a follow up to: 1/17/2025 06:55 Health Status note. Effective Date 1/18/25 at 01:21. Administered 10 units of Lispro as per order at 0645. Resident is alert and verbally responsive. Rechecked fingerstick at 0720am, result 482mg/dl. Oncoming nurse made aware. During a review of Resident 1's Health Status Note, created 1/26/25, the Note indicated Late entry, This note is a follow up to: 1/17/2025 16:14 Health Status note. Effective Date 1/17/25 at 10:05. 7:30 Pt in bed, arousable. Breakfast being served to the residents. Around 8:15, pt in bed awake and responsive. Fingerstick re checked, high. MD was notified. Aware of the 10 units administered in the morning. MD stated he will do rounds. Around 9, pt awake in bed and stated he did not feel like eating. But routine morning meds given and tolerated well. VS WNL. O2 at 96 via NC. Fingerstick re checked at this time at 398. Around 9:40 MD in the facility was notified of patients events regarding his BS (blood sugar) . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055826 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Oaks Post Acute 830 East Chapel Street Santa Maria, CA 93454 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's, Order Summary Report, dated 1/17/25, the Order indicated, Insulin Lispro subcutaneous Pen-Injector 200 unit/ml inject as per sliding scale . subcutaneously before meals for Hyperglycemia. Notify MD if BS <70 or >400; Insulin Lispro subcutaneous Pen-Injector 200 unit/ml inject as per sliding scale . subcutaneously at bedtime for Hyperglycemia . During a review of Resident 1's Weights and Vitals Summary (WVS), the WVS indicated, blood sugar results as follows: 1/9/25 - 144 mg/dl (milligrams per deciliter, a unit of measurement) at 6:38 a.m. 1/10/25 - 252 at 6:47 a.m. 1/11/25 - 385 at 6:30 a.m. 1/12/25 - 390 at 6:17 a.m. 1/13/25 - 296 at 6:30 a.m. 1/14/25 - 389 at 6:24 a.m. 1/15/25 - 498 at 6:10 a.m. 1/16/25 - 388 at 5:31 a.m. 1/17/25 - 500 at 6:03 a.m. During a review of American Medical Response (AMR), document, dated 1/17/25 at 9:48 a.m., the AMR indicated, The patient was found laying on his bed at the SNF. He was A/Ox0. Staff said he is normally A/Ox4. They said he wasn ' t acting normal and they checked his BG. They said it read High. I was unable to get a BG, ours read E-S. He was trauma. Skin signs were normal. Lung sounds rhonchi (low pitched rattling sound) No signs of vomiting. He had a clear open airway. Report and transfer care to the RN. During a review of Resident 1's Emergency Department (ED), document, dated 1/17/25, ED indicated, Reason for visit; clinical diagnosis: altered mental status . Medication list, home meds as of 1/17/25 insulin glargine order date 7/22/18, insulin Lispro order date 7/22/18 . During a review of Resident 1's hospital Discharge Summary, dated 1/18/25, the Discharge Summary indicated, Final diagnoses: 1. Diabetic ketoacidosis with coma. 2. Acute kidney injury related to diabetic ketoacidosis. 3. Ventricular tachycardia (serious heart rhythm disorder with a rapid, irregular heartbeat . Resident 1 (name) is an unfortunate [AGE] year-old man who presented to the ED from the nursing home he was rehabilitating at and was noted to have obtundation. He was sent to the ED and was found to be in diabetic ketoacidosis with his blood glucose at 862. He was with AKI (Acute Kidney Failure) as well with a creatinine of 2.5 and a BUN of 50 . he was extremely dehydrated, somnolent, not really responding to questions appropriately and confused. He was given IV fluid, started on insulin drip and admitted to the ICU. Overnight, the patient ' s blood glucose levels dropped into the 250 range . he had sporadic low blood pressures . later he was noted in the ICU to have persistent bradycardia into the 50's and then at 3:35 he developed ventricular tachycardia and subsequently asystole. Time of death was 3:38 a.m. on 1/18/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055826 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Oaks Post Acute 830 East Chapel Street Santa Maria, CA 93454 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Nursing care of the older adult with diabetes mellitus, revised November 2020, the P&P indicated, Purpose. To provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. For further diabetes education and guidelines, refer to the provider orders and instructions as well as the American Diabetes Association, Standards of Medical Care in Diabetes. Symptoms associated with Diabetes 1) Hyperglycemia. Uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia (blood sugar above target levels) . 2) Diabetic ketoacidosis (DKA) (diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated and the cells begin to metabolize fat for energy . DKA is a life-threatening emergency that needs immediate medical attention . During a review of the facility's P&P titled, Attending Physician Responsibilities/Documentation, revised August 2014, the P&P indicated, The Attending Physicians shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the facility. Each attending physician will be responsible for the following: 1) Accepting responsibility for initial and subsequent resident care; 4) Providing appropriate resident care; 5) Providing appropriate, timely medical orders; Providing appropriate, timely, and pertinent documentation . Accepting Responsibility for Resident Care 1) The Attending Physician will assess new admissions in a timely fashion, according to the individual's medical stability. 2) The Attending Physician will seek, provide, and analyze information regarding a resident ' s current status, recent history, and medications and treatments to enable safe, effective continuing care . 2b) The review should be extensive enough to ensure that the current approach overall is consistent with the individual's medical condition, goals, prognosis, and wishes. Providing Appropriate Care 3) In consultation with facility staff, the Physician will identify appropriate treatments and services, consistent with each individual's diagnoses, condition, prognosis, and wishes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055826 If continuation sheet Page 4 of 4