Health inspection·October 31, 2023

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure for safe discharge plan to address resident's health and safety needs for one of two sampled residents (Resident 1) when Resident 1's blood glucose monitoring (using a device to automatically estimate blood glucose levels) and insulin (insulin: a hormone controls blood sugars) administration was not address upon discharge to the board and care home (B&C home: a residential house that provides care for a small group of seniors). This failure could potentially affect the Resident 1's health and wellness upon discharge from the facility. Residents Affected - Few Findings: Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) undated indicated, Resident 1 was admitted to facility on 8/28/2023. Resident 1's FS also indicated, he was admitted with diagnoses including type 1 diabetes mellitus (a disease in which the body does not make enough insulin to control blood sugar levels), hyperglycemia (increased blood sugar levels), long term use of insulin, carpel tunnel syndrome (a numbness and tingling sensation in the hand and arm caused by a pinched nerve in the wrist), chronic viral hepatitis C (an infection caused by a virus that attacks the liver), and need for assistance with personal care. Resident 1 was discharged to B&C home on 9/12/023. Review of Resident 1's minimum data set (MDS: Clinical functional assessment tool) assessment dated [DATE] indicated Resident 1's brief interview for mental status (BIMS) score of 14 of 15 (13-15: cognitively intact). Review of Resident 1's physician orders dated 8/28/2023 indicated, Resident 1 had an order for Humalog (fast acting insulin used to treat to control high blood sugar levels in the body) Solution 100 Unit/ML (unit per milliliter: a unit of fluid volume equal to one-thousandth of a liter) Inject as per sliding scale (SS: varies the dose of insulin based on the blood glucose level): If 0-60 =0 units, Follow hypoglycemia (low blood sugar levels) Protocol; 70-150 =0 units; 151 -200 =2 units; 201-250=4 units; 251-300 =6 units; 301 -350 =8 units; 351 -400 =10 units; 401 + call Prescriber, subcutaneously (a short needle is used to inject a drug just under the skin) with meals and as needed for diabetes. Review of Resident 1's physician orders dated 8/28/2023 indicated, Resident had an order for Humalog 100 Units/ML Inject as per SS: If 0-69 =0 units, Follow hypoglycemia Protocol; 70-150= 0 units; 151-200=1 units; 201-250= 2 units; 251-300 = 3 units; 301-350 = 4 units; 351-400 = 5 units; 401+call Prescriber, subcutaneously at bedtime for diabetes. Review of Resident 1's physician orders dated 9/05/2023 indicated, Insulin Glargine (long-acting Page 1 of 3 055866 055866 10/31/2023 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insulin that works slowly over about 24 hours to control blood sugar levels) Solution 100 Units/ML Inject 30 units subcutaneously every 12 hours for diabetes. Review of Resident 1's physician orders upon discharge to B&C home on 9/12/2023 indicated, insulin glargine 100 unit/ml solution inject 30 units subcutaneously every 12 hours, Humalog solution 100 units/ml inject subcutaneously as per sliding scale with each meal, at bedtime, and as needed for diabetes. Review of Resident 1's physician orders dated 9/11/2023 indicated, May DC home 9/12/2023 w/PT (physical therapy: a care that aims to ease pain, and help function, move and strengthen muscles) /OT (occupational therapy: helps to learn and regain skills of daily living)/ RN (registered nurse: licensed medical professional who provides hands- on care to residents)/HH (home health: a wide range of health care services that can be given at home for an illness or injury). Resident 1's IDT (interdisciplinary team: a group of dedicated healthcare professionals who work together to provide the care resident needs and when needed) planned Discharge summary dated [DATE] indicated, Resident 1 was discharge with medication list. Further review of this discharge summary indicated, no documented evidence of IDT discussed and implemented the plan to meet Resident 1's blood glucose monitoring, and insulin administration care needs at B&C home after discharged from facility on 9/12/2023. Review of Resident 1's nursing Discharge summary dated [DATE] at 17:26 indicated, Pt discharged to B&C home @ 1600. Pt discharged on w/c (wheelchair: a chair on wheels that people who are unable to walk use for moving around), picked up by the driver of the receiving facility. Review of Resident 1's clinical record indicated, there was no documented evidence of facility planned, implemented, and confirmed to meet Resident 1's blood glucose monitoring, and insulin administration care at the B&C home after his discharge from facility. Further review of Resident 1's clinical record indicated, there was no documented evidence of B&C home staff evaluated Resident 1's blood glucose monitoring, and insulin administration care needs to meet at the B&C home before accepted Resident 1 from facility. During an interview with primary care physician (PCP) for Resident 1 on 10/12/2023 at 12:30 p.m., PCP stated she (PCP) was not involved with discharge plan for Resident 1. PCP confirmed Resident 1 needed to continue monitoring for blood glucose and insulin administration for diabetes at B&C home. PCP also stated facility did not verify whether B&C home was capable to continue Resident 1's insulin administration, and blood glucose monitoring care at B&C home before discharged Resident 1. PCP further stated facility unsafely discharged Resident 1 to B&C home without evaluated and confirmed the B&C home's capabilities to meet Resident 1's need for on-going diabetes management. During a concurrent interview and record review with licensed vocational nurse/unit manager A (LVN/UM A) on 10/12/2023 at 2:05 p.m., LVN/UM A confirmed she attended IDT discharge meeting for Resident 1 on 9/11/2023. LVN/UM A also confirmed Resident 1 was discharged to B&C home with physician orders including blood glucose monitoring and insulin administration on 9/12/2023. LVN/UM A stated IDT did not discuss the plan for Resident 1 ' s blood glucose monitoring, and insulin administration care needs at B&C home upon discharge from facility to B&C home. LVN/UM A further stated facility should have discussed and planned safe discharge to meet Resident 1's blood glucose management at the B&C home before discharged from facility. 055866 Page 2 of 3 055866 10/31/2023 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with social service director (SSD) on 10/12/2023 at 2:15 p.m., SSD confirmed Resident 1 had physician orders for blood glucose monitoring and insulin administration at B&C home. SSD also confirmed IDT did not discuss Resident 1's blood glucose monitoring, and insulin administration care needs at the B&C home after discharge from facility. SSD stated staff from B&C home did not evaluate Resident 1's care needs to meet for blood glucose monitoring and insulin administration at B&C home upon the discharge from facility. SSD also stated facility failed to verify and confirm whether B&C home had the capacity to monitor blood glucose, and administer insulin as ordered by physician before discharged to B&C home on 9/12/2023. SSD further stated facility should have discharged Resident 1 with a safe discharge plan to meet blood glucose monitoring and insulin administration arrangements at B&C home as required for Resident 1 before discharged him to B&C home from facility. During a concurrent interview and record review with director of nursing (DON) on 10/12/2023 at 3:45 p.m., DON confirmed IDT did not discuss the plan to meet Resident 1's blood glucose monitoring, and insulin administration orders at the B&C home after discharged from facility. DON stated IDT should have discussed, planned, and arranged to meet diabetic care needs at B&C home for a safe discharge plan for Resident 1. DON also stated SSD should have verified and confirmed with B&C home to meet Resident 1's on-going diabetic management care before Resident 1 discharge to the B&C home. DON further stated Resident 1 had unsafe discharge to B&C home. Review of facility's policy and procedure (P&P) titled, Discharging the Resident, dated 7/1/2020, the P&P indicated, If the resident is being discharged home, ensure that resident and/or responsible party (RP: who is given authority to act on behalf of the resident for daily decision making) receive teaching and discharge instructions. 055866 Page 3 of 3