Health inspection·October 21, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain a physician order to provide services in accordance with standards of care when admission orders for one resident, (Resident 1), did not include blood glucose monitoring (a process of regularly measuring the amount of sugar in the blood) before each meal and before bed. Residents Affected - Few This failure had the potential for Resident 1 ' s blood glucose level to be undetected and untreated. Findings: On 10/17/24 the State Agency (SA) received a complaint that indicated Resident 1 ' s blood glucose was checked once per day and reached 477 (elevated above 70-99, a recommended range). Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type two (a disease in which blood sugar is higher than normal and can cause permanent damage to the body). On 10/21/24 at 12:10 P.M. an unannounced visit was conducted at the facility. Resident 1 was discharged from the facility on 9/30/24. On 10/21/24 at 12:30 P.M. an interview was conducted with Licensed Nurse (LN) 2 who stated, We do blood glucose checks before meals. If there ' s no order for that, I ' d call the doctor. On 10/21/24 at 4:10 P.M. an interview and concurrent record review were conducted with the Director of Nursing (DON). Resident 1 ' s physician orders indicated she was receiving two types of insulin upon admission. The admission orders indicated blood glucose monitoring was to be performed once per day at 5 P.M. A joint review of Resident 1 ' s blood glucose monitoring indicated documentation started on 9/13/24 at 8:24 A.M. and continued once per day until 9/25/24 when monitoring happened three times, four times on 9/26/24, two times on 9/27/24, four times on 9/28/24, five times on 9/29/24, and three times on 9/30/24 which was the date of Resident 1 ' s discharge. A joint review of a change of condition document dated 9/25/24 indicated, Patient ' s husband requested to have her blood sugar checked as he stated she was acting differently.Blood sugar check result 477. MD (Medical Doctor) notified. 9/25/24 2030 (8:30 P.M.) awaiting reply. The DON stated when they come from the hospital we continue the orders. The physician ordered monitoring once per day. We did not question the frequency of monitoring that was ordered. The order for blood glucose checks increased to four times a day on 9/26/24 after her husband brought up a concern. The DON stated the facility practice regarding blood glucose monitoring of a resident on insulin was usually before each meal and sometimes also at (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056062 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 056062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amaya Springs Health Care Center 8625 Lamar Street Spring Valley, CA 91977 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)