Health inspection·December 26, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) out of three sampled residents was free from a significant medication error when:Resident 1 did not have a person-centered care plan that included the administration of glucagon (emergency treatment to raise blood sugar levels) during a hypoglycemic episode (when a person's blood sugar level drops below 70 milligrams per deciliter (a unit of measurement)) nor one for Resident 1's risk for refractory hypoglycemia;Licensed Nurse 2 (LN 2) documented that insulin was administered at 11:30 a.m. when it was supposed to be given at 6:30 a.m.;The facility's glucometer had not been tracking accurate dates or times;LN 2 did not document Resident 1's blood glucose value of 434 mg/dl and did not notify the physician;LN 2 administered a total of 16 units of insulin to Resident 1 within 1 hour and 18 minutes;LN 2 did not use a Spanish language interpreter to communicate with Resident 1 when LN 2 administered insulin; and,LN 1 did not administer glucagon per the facility's protocol via intramuscular (into a large muscle) injection when Resident 1 became unresponsive with a blood glucose level of 50.This failure resulted in Resident 1 receiving life-threatening and invasive treatment at a local hospital emergency room.Findings:A review of Resident 1's admission record indicated admission to the facility on 4/23/25 with diagnoses of End Stage Renal Disease (ESRD- a condition in which kidneys are severely damaged and can no longer function on their own) with dependence on renal dialysis (a life-sustaining treatment that filters waste and excess fluid from the body when the kidneys fail) and Type 2 Diabetes Mellitus (DM- a chronic condition in which the body has difficulty in controlling blood sugar levels).A review of Resident 1's focused care plan, dated 4/23/25, for DM indicated Resident 1's goal was to be free of signs or symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) and to minimize the risk of DM. To assist Resident 1 to reach his goal, nursing staff were expected to: monitor for signs and symptoms of hypo/hyperglycemia; implement interventions to manage hypo/hyperglycemic events; and perform blood glucose checks as ordered. The care plan also indicated Resident 1 experienced a hypoglycemic event on 8/1/25 at which time Resident 1 was given glucagon, but the administration of glucagon was not included in the care plan as a nursing intervention. A further review of all of Resident 1's care plans dated 4/23/25 to 11/2/25 showed no documented evidence of a focused person-centered care plan that indicated he had refractory hypoglycemia.A review of Resident 1's weights and vitals summary indicated Resident 1's blood glucose level on 8/1/25 was 45 mg/dL.A review of Resident 1's Minimum Data Set (an assessment tool) dated 8/5/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident 1 had moderate impairment to his ability to process knowledge and understanding.A review of MD orders dated 10/8/25 at 4:30 p.m., indicated the physician ordered [Brand name insulin lispro (a rapid acting insulin used to decreased high levels of blood glucose; it starts working within 5 minutes and its maximum effect occurs between 30 to 90 minutes)] Subcutaneous Solution Pen-injector [a pre-filled, disposable insulin pen which delivers insulin] 100 UNIT/ML [milliliter-a unit of measure] Inject as per sliding scale Residents Affected - Few Page 1 of 5 055854 055854 12/26/2025 Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405

F 0760 Level of Harm - Actual harm Residents Affected - Few [a method of determining a dosage based on a person's current blood glucose level]: if 70 - 150 = 0. If BG [Blood Glucose] under 70, give 0 units, and initiate hypoglycemic protocol, recheck in 30 min [minutes] and notify MD [physician]; if [BG] 151- 200= [give] 2 [units of insulin]; 201- 250= 4; 251-200= 6; 301-350= 8; 351- 400= 10; 401+= 12.before meals and at bedtime for DM.A review of Resident 1's Medication Administration Record (MAR) dated November 2025 indicated on 11/2/25:-At 6:30 a.m. Resident 1's blood glucose level was 317 and he was given 8 units of insulin lispro.-At 11:30 a.m. Resident 1's blood glucose level was 317 and he was given 8 units of insulin lispro.A review of Resident 1's Location of Administration Report dated November 2025 indicated on 11/2/25 at 11:07 a.m. LN 2 administered insulin to Resident 1 at 11:07 a.m. when it was scheduled to be administered at 6:30 a.m. LN 2 also administered a second dose of insulin to Resident 1 at 12:25 p.m. resulting in Resident 1 receiving two doses of insulin within a time frame of 1 hour and 18 minutes.A review of Resident 1's facility document titled .Healthcare Providers-Return to Acute (Unplanned Discharge) dated 11/2/25 at 7:12 p.m., indicated, .Change of Condition.[Resident 1 is] insulin Dependent DM, Received insulin this AM [morning] with breakfast. Nursing team noted [Resident 1] to have AMS [Altered Mental Status]. BS [blood sugar] = 50. Unable to give oral dextrose [glucose gel- over the counter medication to rapidly treat low blood sugar].Intervention attempted: Called 911 for refractory hypoglycemia [a severe, prolonged low blood sugar state that resists standard treatments like consuming sugar; causes include extremely high insulin doses; unlike typical hypoglycemia that resolves quickly, refractory episodes can last for extended periods].[Resident 1] was sent to the ED [emergency department] for emergent evaluation.A review of Resident 1's progress note dated 11/2/25 at 10:01 p.m., indicated, at [2:40 p.m.].assessed [Resident 1] and found [Resident 1] not very responsive and very sweaty. After a sternal [sic] rub [Resident 1] tried to speak but could not complete a sentence.tried to give [Resident 1] orange juice and glucose gel but [Resident 1] would spit it out.called 911.paramedics arrived and took [Resident 1] at [3:20 p.m.]. At about [9:30 p.m.] received call from.[hospital nurse].wanted to investigate how [Resident 1] got to how he was. [Resident 1] arrived back into facility at [9:35 p.m.] and states that he was unhappy with AM nurse. A review of Resident 1's hospital Emergency Department provider note dated 11/2/25 indicated, .[3:49 p.m. Resident 1] BIBA [brought in by ambulance] as code critical.EMS [Emergency Medical Services] reported secretions, required suctioning.facility reported high BG, [Resident 1] received 8u [units] insulin [Resident 1] presents to ED with a chief complaint of AMS, low blood sugar. Per EMS staff at his facility noted he was altered and had low blood sugar of 36. [Resident 1] is normally GCS [Glascow Coma Scale (a neurological assessment tool used to measure a person's level of consciousness scoring 3-15, where a low score indicates a more severe impairment of consciousness] 15, AOX4 [Awake, oriented to person, place, time, and event] but upon EMS arrival [Resident 1] was GCS 8 and had blood sugar of 30.EMS states they had issues with access and had to place IO [Intraosseous device- a large bore needle which enables rapid access for healthcare providers to administer fluids and medications directly into the marrow cavity of a large bone]. [Resident 1] has had half a bag of D10 [an IV fluid with high sugar content] and had improvement of his mentation.[9:31 p.m. Hospital Nurse] talked to [LN 1]. He [LN 1] arrived at 2 [p.m.]. States [LN 2].gave.insulin earlier today around lunch time states [Resident 1's] BS [blood sugar] = 200 prior to lunch.[LN 1] unsure about how much [insulin] was given. At some point the blood sugar after was 70 and [Resident 1] was awake at the time.[Resident 1] states that he didn't like [LN 2].States he didn't listen to [Resident 1].A review of the Interdisciplinary Team (IDT-a group of healthcare professionals who meet to discuss and provide comprehensive care) note, dated 11/3/25 at 9 a.m., indicated, On 11/2[/25] at [2:40 p.m.] [Resident 1] had a hypoglycemic episode in which 055854 Page 2 of 5 055854 12/26/2025 Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405

F 0760 Level of Harm - Actual harm Residents Affected - Few his [glucose] was 50, had decreased responsiveness and sweaty. He was unable to take OJ [orange juice] po [by mouth] and did not respond fully to sternal rub. Per MD [physician] [Resident 1] was sent to the ER [Emergency Room]. [Resident 1] returned at [9:35 p.m.] that evening to resume his normal plan of care, no new orders received.During an interview in the facility conference room on 11/6/25 at 12:32 p.m., with the use of an interpreter service Resident 1 stated he has had diabetes for over 20 years and was recently started on insulin. Resident 1 stated he has learned that he does not feel well when he was given too much or too little insulin, and how his blood sugar levels are dependent upon what he eats. Resident 1 stated that on Sunday, 11/2/25, he was not feeling well. Resident 1 stated his stomach felt off and he had been vomiting. Resident 1 stated when LN 2 came into his room with his insulin shot, Resident 1 stated he did not want it. Resident 1 stated he told LN 2 he had been vomiting and was not feeling well; however, LN 2 administered the insulin despite Resident 1's refusal. Resident 1 stated when he looked at the syringe that contained the insulin, it appeared like it was too much. Resident 1 stated Spanish was his primary language and LN 2 did not use an interpreter to communicate with him when he came in to give him his insulin. During an interview on 11/6/25 at 1:27 p.m., LN 3 stated the hypoglycemic protocol was to administer glucagon intramuscularly for blood sugars below 70 with an unresponsive resident. LN 3 further stated if the resident was responsive, then give the resident a snack. During a concurrent interview and record review in the Director of Nursing (DON) office on 11/6/25 at 2:51 p.m., the DON and the Assistant Director of Nursing (ADON) stated Resident 1 informed the ADON he had not wanted all the insulin, but LN 2 administered it to him anyway. The DON reviewed the Location of Administration report and confirmed it appeared as though LN 2 gave insulin twice within 1 hour and 18 minutes.During a follow-up interview on 11/6/25 at 3:15 p.m., with the use of an interpreter service, Resident 1 stated LN 2 only gave him one dose of insulin on 11/2/25.During a phone interview on 11/6/25 at 3:26 p.m., LN 2 stated the night shift nurse (LN 4) obtained Resident 1's blood sugar value before she left on 11/2/25 but did not document the blood sugar value in Resident 1's MAR. LN 4 reported to LN 2 Resident 1's blood sugar level was 317. LN 2 stated he manually entered the blood sugar value (317) in the MAR and gave 8 units of insulin lispro as per sliding scale before breakfast when he noticed the breakfast carts were in the hallway. LN 2 stated he did not normally administer insulin based on another blood sugar value that was obtained by another nurse nor documented but knew Resident 1 had an insulin order. LN 2 further stated the insulin had not been administered late but was documented late. LN 2 stated he obtained another blood glucose value for Resident 1 when the lunch carts arrived around 12 p.m. LN 2 stated the blood sugar value at that time was 349 but accidentally entered a value of 317 in the MAR. LN 2 then stated he administered another 8 units of insulin lispro to Resident 1. LN 2 stated he did not speak Spanish and had asked his co-worker, Certified Nursing Assistant 1 (CNA 1) to translate for him during the shift. LN 2 stated Resident 1 did not refuse his insulin, nor did Resident 1 tell CNA 1 he wasn't feeling well or had vomited. LN 2 stated he obtained another blood sugar value from Resident 1 before leaving for the day and it was 77. LN 2 further acknowledged his documentation in Resident 1's chart on 11/2/25 was very minimal and reiterated he was very busy. During a further interview and equipment review in the facility conference room on 11/6/25 at 3:55 p.m., the DON stated she had not thought to review the history of blood sugars on Resident 1's glucometer. The DON stated the glucometer was shared by other residents in the same hall as Resident 1. The DON acknowledged the glucometer did not have the correct date or time displayed on the screen; therefore, all historical blood sugar values were off by a considerable number of days and hours. The DON also acknowledged that the glucometer did not have any resident names or ID numbers associated with any blood sugar values. 055854 Page 3 of 5 055854 12/26/2025 Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405

F 0760 Level of Harm - Actual harm Residents Affected - Few Through a process of elimination, the following blood sugar values were located and confirmed by the DON as belonging to Resident 1 on 11/2/25: 317, 434, 77, 50. The DON stated she could not find a blood sugar value of 349 as reported by LN 2 during the interview. The DON confirmed that the value of 434 would have necessitated a call to the physician.During a phone interview on 11/6/25 at 5:24 p.m., CNA 1 stated he translated once for Resident 1 and LN 2 on 11/2/25. CNA 1 did not recall the conversation exactly but stated it did not involve insulin.During a phone interview on 11/7/25 at 10:39 a.m., LN 2 corrected his earlier statement and stated CNA 1 translated for him once on 11/2/25. LN 2 stated that on 11/2/25 at 11:30 a.m., he obtained a blood sugar value of 434 and had incorrectly stated 317 and 349. LN 2 stated, . I might have made a mistake and mixed up some insulins or gave the wrong dose. It was a bad day. LN 2 stated he felt very overwhelmed on 11/2/25, as he normally worked the night shift and did not realize day shift was so busy. LN 2 stated he did not have time to think. He had multiple residents with blood sugar checks and insulin in the morning and again at lunchtime. LN 2 stated he did not document his morning insulin administration until later that morning around 11 a.m. and further stated, I must have forgot, it was so busy. During a phone interview on 11/6/25, at 12:20 p.m., LN 4 stated she normally took Resident 1's blood sugar value in the morning and would only give insulin on days Resident 1 was scheduled to leave for dialysis (medical treatment to remove excess waste and fluid from the blood when the kidneys fail) because Resident 1 was given an early breakfast tray on those days. LN 4 remembered giving LN 2 Resident 1's blood sugar value during shift change report on 11/2/25 but did not document the value in the MAR. LN 4 stated not documenting information was not normal practice, but she was attending to the need of another resident. During a phone interview on 11/7/25 at 3:33 p.m., the Medical Director 1 (MD 1) stated because Resident 1 had ESRD with DM, he was prone to erratic swings in blood sugar levels. MD 1 confirmed glucagon administration would have been appropriate in this situation.A review of Resident 1's order listing report indicated the physician placed the following order for Resident 1 on 11/7/25, Glucagon Emergency Kit 1 mg [milligram, a unit of measurement].Inject 1 mg intramuscularly as needed for (Severe Hypoglycemia/DM) Notify MD. Inject 1 mg as needed if receiving insulin, unresponsive, or unable to take PO snack or glucogel. Recheck FSBG [fingerstick blood glucose] in 30 minutes.A review of Resident 1's blood sugar values, dated 7/4/25-11/18/25, indicated Resident 1's blood sugar values remained stable with three values below 70 over a period of four months.During an interview in the DON's office on 11/18/25 at 12:05 p.m., the DON stated she and MD 1 reviewed all residents on sliding scale insulin and placed orders for glucagon to be given in cases of severe hypoglycemia.During a phone interview on 11/18/25 at 4:01 p.m., LN 1 stated he entered Resident 1's room for the first time that shift on 11/2/25 after a co-worker told him Resident 1 didn't look right. LN 1 stated Resident 1 was not making any sense. LN 1 stated he took a blood glucose value from Resident 1, and the value was 50. LN 1 stated, I tried giving him orange juice, but he wouldn't swallow it. It just ran out of his mouth. LN 1 stated he then tried the glucose gel, thinking it was thicker, and Resident 1 would be able to get it down better, but that fell out of his mouth too. LN 1 stated he quickly tried to look for the glucagon in the medication room and could not find it. LN 1 stated he did not think to open the Emergency Kit (E kit- a pre-assembled supply of essential and emergency medications kept in skilled nursing facilities) to obtain the glucagon. LN 1 further reported that during shift change report, LN 2 reported Resident 1 had received insulin, and a recheck of Resident 1's blood sugar value was 77. LN 1 stated he did not question why LN 2 rechecked Resident 1's blood sugar when it was not time for it to be checked. A review of the facility's policy titled Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including 055854 Page 4 of 5 055854 12/26/2025 Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405

F 0760 Level of Harm - Actual harm Residents Affected - Few any required time frame.The individual administering the medication checks.to verify.the right resident, right medication, right dosage, right time.before giving the medication.A review of the facility's policy titled Charting and Documentation revised July 2017 indicated, The following information is to be documented in the resident medical record.Objective observations; Medications administered; Treatments or services performed; Changes in the resident's condition; Events, incidents, or accidents involving the resident.Documentation in the medical record will be objective.complete, and accurate.Documentation of procedures and treatments will include care-specific details, including.whether the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification or family, physician or other staff.A review of facility policy titled Management of Hypoglycemia, revised 3/25, indicated If a resident has .hypoglycemia and is unresponsive .administer 1 mg [milligram-a unit of measure] of glucagon subcutaneously [a method of administering medications underneath the skin]. A review of the American Diabetes Association's guideline titled Hypoglycemia for healthcare professionals, dated 2025, indicated, Hypoglycemia is categorized into three levels based on glucose levels and symptom severity.Level 2 Blood glucose less than 54 mg/dL.Level 3 [most severe] Altered mental and/or physical status requiring assistance, irrespective of glucose level.Assess hypoglycemia risks.such as recent episodes, insulin.kidney disease.Reevaluate treatment plan if experiencing level 2 or 3 hypoglycemia.Prescribe glucagon for all on insulin. Glucagon preparations not requiring reconstitution [to be mixed prior to being used] are preferred. Glucagon is indicated for hypoglycemia treatment when people are unable to.consume carbohydrates [sugar] by mouth.Non-health care professionals can safely administer glucagon. 055854 Page 5 of 5