Health inspection·August 26, 2025

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's plan of care was revised to address Resident 1's refusal of insulin as ordered by the physician for the management of diabetes mellitus. This failure has the potential to pose the risk of not providing Resident 1 with appropriate and individualized care.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care revised 12/2023 showed the facility IDT will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident. Closed medical record review for Resident 1 was initiated on 8/22/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/14/25, showed Resident 1 was admitted to the facility with diagnoses including Type 2 Diabetes and had the capacity to understand and make medical decisions. Review of Resident 1's Order Summary Report showed a physician's order dated 4/15/25, for Resident 1 to receive insulin Glargine Solution (antidiabetic) 100 units/ml 12 units subcutaneously at bedtime for diabetes. Hold for blood sugar less than 90 mg/dl. Review of Resident 1's MAR from April to June 2025 showed the following nursing documentation with the designated chart code 1: refusal, 10: hospitalized and 14: no insulin required:- dated 4/15/25, BS (blood sugar) of 136 mg/dl, chart code 1 - dated 4/16/25, BS of 133 mg/dl, chart code 1- dated 4/17/25, BS of 151 mg/dl, chart code 1- dated 4/18/25, BS of 146 mg/dl, chart code 1- dated 4/21/25, BS of 134 mg/dl, chart code 1- dated 4/27/25, BS of 127 mg/dl, chart code 1- dated 4/28/25, BS not available, chart code 1- dated 4/29/25, BS of 144 mg/dl, chart code 1- dated 5/1/25, BS of 116 mg/dl, chart code 1- dated 5/2/25, BS of 185 mg/dl, chart code 1- dated 5/3/25, BS of 166 mg/dl, chart code 1- dated 5/4/25, BS of 136 mg/dl, chart code 1- dated 5/5/25-5/7/25, BS not available, chart code 1dated 5/8/25, BS of 178 mg/dl, chart code 1- dated 5/9/25, BS not available, chart code 1- dated 5/10/25, BS of 114 mg/dl, chart code 1- dated 5/11/25, BS of 148 mg/dl, chart code 1- dated 5/12/25-5/14/25, BS not available, chart code 1- dated 5/15/25, BS of 128 mg/dl, chart code 1- dated 5/16/25, BS not available, chart code 1- dated 5/17/25, BS of 116 mg/dl, chart code 1- dated 5/18/25, BS of 127 mg/dl, chart code 1dated 5/19/25-5/21/25, BS not available, chart code 1- dated 5/22/25, BS of 173 mg/dl, chart code 1- dated 5/23/25-5/28/25, BS not available, chart code 1- dated 5/29/25, BS of 150 mg/dl, chart code 1- dated 5/30/25, BS of 90 mg/dl, chart code 14- dated 6/1/25, BS of 150 mg/dl, chart code 1- dated 6/2/25, BS not available, chart code 1- dated 6/3/25, BS not available, chart code 1- dated 6/4/25, BS not available, chart code 1 Review of Resident 1's plan of care for Diabetes mellitus initiated on 4/28/25, showed interventions included checking the blood sugar and administering insulin as ordered. However, the plan of care was not revised to reflect Resident 1's refusal of the medication and education with risks associated with the refusal. On 8/26/25 Page 1 of 3 055983 055983 08/26/2025 Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some at 1242 hours, an interview and concurrent closed medical record review was conducted with MDS Nurse 1. MDS Nurse 1 verified the above findings. MDS Nurse 1 stated Resident 1's plan of care interventions should have been updated to reflect Resident 1's refusal of the medication as ordered, ongoing monitoring of resident's glucose level and risks associated with medication refusal for the treatment and management of diabetes. On 8/26/25 at 1605 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON acknowledged and verified the above findings. 055983 Page 2 of 3 055983 08/26/2025 Coventry Court Health Center 2040 S. Euclid Avenue Anaheim, CA 92802

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained their highest practicable physical well-being. * The facility failed to notify the physician when Resident 1 consistently refused insulin as ordered. This failure posed the risk of Resident 1 not being provided with appropriate care and monitoring of possible complications associated with diabetes mellitus.Findings: Review of the facility's P&P titled Diabetes Management dated 5/2019 showed medications for diabetes will be administered as ordered by the physician including oral hypoglycemic or insulin. Review of the facility P&P titled Administration of Medication (undated) showed medications must be administered in accordance with the written orders of the attending physician. Should a drug be withheld, refused or given other than at the scheduled time, the staff administering must indicate the reason on the MAR. For those utilizing eMARs, the appropriate code must be entered with follow up documentation as appropriate for the situation. Closed medical record review for Resident 1 was initiated on 8/22/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/14/25, showed Resident 1 was admitted to the facility with diagnoses including Type 2 diabetes and had the capacity to understand and make medical decisions. Review of Resident 1's Order Summary Report showed a physician's order dated 4/15/25, for Resident 1 to receive insulin Glargine Solution (antidiabetic) 100 units/ml 12 units subcutaneously at bedtime for diabetes. Hold for blood sugar less than 90. Review of Resident 1's MAR from April to June 2025 showed the following nursing documentation with the designated chart code 1: refusal, 10: hospitalized and 14: no insulin required:- dated 4/15/25, BS of 136 mg/dl, chart code 1 - dated 4/16/25, BS of 133 mg/dl, chart code 1- dated 4/17/25, BS of 151 mg/dl, chart code 1- dated 4/18/25, BS of 146 mg/dl, chart code 1- dated 4/21/25, BS of 134 mg/dl, chart code 1- dated 4/27/25, BS of 127 mg/dl, chart code 1- dated 4/29/25, BS of 144 mg/dl, chart code 1- dated 5/1/25, BS of 116 mg/dl, chart code 1- dated 5/2/25, BS of 185 mg/dl, chart code 1- dated 5/3/25, BS of 166 mg/dl, chart code 1- dated 5/4/25, BS of 136 mg/dl, chart code 1- dated 5/8/25, BS of 178 mg/dl, chart code 1- dated 5/10/25, BS of 114 mg/dl, chart code 1- dated 5/11/25, BS of 148 mg/dl, chart code 1- dated 5/15/25, BS of 128 mg/dl, chart code 1- dated 5/17/25, BS of 116 mg/dl, chart code 1- dated 5/18/25, BS of 127 mg/dl, chart code 1- dated 5/22/25, BS of 173 mg/dl, chart code 1dated 5/23/25-5/28/25, BS not available, chart code 1- dated 5/29/25, BS of 150 mg/dl, chart code 1- dated 5/30/25, BS of 90 mg/dl, chart code 14- dated 6/1/25, BS of 150 mg/dl, chart code 1- dated 6/2 to 6/4/25, BS not available, chart code 1Further review of Resident 1's medical record failed to show documented evidence the physician was notified of the resident's consistent refusal of insulin. On 8/26/25 at 1242 hours, an interview and concurrent closed medical record review was conducted with MDS Nurse 1. MDS Nurse 1 verified the above findings. MDS Nurse 1 stated there should have been documentation to show the physician was informed regarding refusal of medication or treatment as ordered. On 8/26/25 at 1605 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON acknowledged and verified the above findings. 055983 Page 3 of 3