Health inspection·October 30, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Diabetic Management and Insulin Administration, which indicated the facility will ensure safe, timely, and effective monitoring of blood sugar (BS) and administration of insulin in accordance with physician orders and regulatory standards, for one of 3 sampled residents (Resident 1), who was diagnosed with diabetes mellitus type 2 ([DM], a disorder characterized by difficulty in BS control and poor wound healing). The facility failed to:1. Ensure Resident 1's primary care provider (PCP) was aware Resident 1 did not have orders for monitoring BS levels, and insulin coverage. 2. Ensure Resident 1 had orders for BS monitoring and insulin coverage as indicated. 3. Ensure the licensed staff assigned to Resident 1 were aware of Resident 1's diagnosis of DM and monitored the resident's BS for signs and symptoms of hyperglycemia ([high BS] such as blurred vision, fatigue, increased thirst, fruity-scented breath, confusion and loss of consciousness) and hypoglycemia ([low BS] such as sweating, dizziness, hunger, anxiety, difficulty concentrating, and slurred speech). 4. Implement Resident 1's Plan of Care, titled Diabetes Mellitus, Uncontrolled High Blood Sugar Results initiated 9/27/2025 which indicated to monitor Resident 1's BS through finger sticks (a simple procedure where a small amount of blood is collected from the fingertip for testing), and signs and symptoms of hyperglycemia As a result of these deficient practices, on 10/21/2025 Resident 1 was admitted to a general acute care hospital (GACH), diagnosed with hyperglycemia and Diabetic ketoacidosis ([DKA], a life-threatening complication of diabetes that occurs when the body does not have enough insulin and is left untreated for a prolonged length of time), which had the potential to cause Resident 1 to fall into a diabetic coma (a condition when the body is overwhelmed with the amount of BS levels, and the resident cannot wake up or respond purposefully to the environment) and possibly death.Findings A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included DM with DKA without coma, chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products from the blood, leading to a buildup of toxins and other harmful substances in the body), and quadriplegia (cannot move or feel their arms and legs due to injury).A review of Resident 1's Care Plan titled, Diabetes Mellitus, Uncontrolled High Blood Sugar Results, indicated to monitor Resident 1 for signs and symptoms of hyperglycemia, monitor BS through finger sticks, and notify the PCP of signs and symptoms of uncontrolled BS A review of Resident 1's Order Summary Report dated 9/27/2025 indicated:-Empagliflozin oral (medication used to treat DM by removing excess sugar from the blood and lowering BS) tablet 10 milligrams ([mg] unit of measurement), give 1 tablet via g-tube (plastic tube surgically inserted into the stomach to provide medications and nutrition) one time a day for DM, -Insulin Regular Human Injection Solution ( a short-acting insulin solution [starts to work after about 30 to 60 minutes and usually lasts up to 8 hours] used to manage high BS levels in individuals with diabetes) 100 units/milliliter (ml Residents Affected - Few Page 1 of 4 056433 056433 10/30/2025 Vermont Healthcare Center 22035 S. Vermont Avenue Torrance, CA 90502

F 0684 Level of Harm - Actual harm Residents Affected - Few unit of measure of volume) inject per sliding scale (insulin amount administered based on the level of the BS and the PCP's order for that level of BS) A review of Resident 1's History and Physical (H&P) dated 9/28/2025, indicated Resident 1 could make his needs known but could not make medical decisions.A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 10/7/2025, indicated Resident 1 was rarely/never understood. The MDS indicated Resident 1 was dependent (helper does all the effort to complete the task) for activities of daily living (ADL: hygiene, bathing and getting dressed and mobility functions such as transfers, rolling and sitting up in bed.A review of Resident 1's Order Summary Report, dated 10/13/2025, indicated Lantus, a long-acting insulin which provides a slow, steady release of insulin into the bloodstream to help maintain stable BS levels throughout the day and overnight] to regulate BS) Subcutaneous (injection applied under the skin) solution 100 units/mL (a unit of measurement, used for medication dosage and/or amount) Inject 10 units subcutaneously at bedtime for DM. The Order Summary Report did not include any other orders to monitor or treat Resident 1's diagnosis of DM such as orders for insulin (short-acting) diabetes and BS monitoring for Resident 1.A review of an online article from the American Diabetic Association (a nonprofit organization that funds research to prevent, cure and manage diabetes) website titled Diabetes and DKA (Ketoacidosis) 11/12/2025, DKA was a life-threatening condition that could lead to diabetic coma and death. The article indicated treatment for DKA took place in the GACH but could be prevented by learning the warning signs and checking BS regularly. (https://diabetes.org)A review of Resident 1's Medication Administration Record (MAR) dated 10/1/2025 through 10/31/2025, indicated facility staff administered Lantus Subcutaneous solution 10 units daily to Resident 1 from 10/1/2025 to 10/7/2025 (7 doses of 10 units each) and again daily from 10/14/2025 until 10/20/2025 (7 doses of 10 units each). A review of the facility's blood glucose monitoring machine user instruction manual, revised 10/2024, indicated if a resident's BS level was above 600 mg/dl, the reading will appear as HI on the screen. The user manual indicated the test should be repeated, and if it indicated HI again, the healthcare professional should be contacted immediately. A review of Resident 1's Change in Condition (CIC), dated 10/21/2025 and timed at 12:50 a.m., indicated Resident 1 had high BS that could not register on the glucometer. The CIC indicated Resident 1 had an altered level of consciousness (ALOC not able to respond normally), tachypnea (abnormal rapid, shallow breathing) and oxygen desaturation (an unhealthy decrease in the blood's oxygen levels). The CIC indicated Resident 1 was hypotensive, (low blood pressure),systolic blood pressure (the pressure of blood when the heart pushes blood out to the rest of the body] was 87 millimeters of mercury (mm Hg, unit of measure), (reference range is 90 -120mm Hg), and the diastolic (the measurement between pressure when the heart is filling with blood) was 46 mm Hg, (reference range 60-80 mm Hg). The CIC indicated the facility staff notified Resident 1's DNP who ordered Resident 1 to be transferred to the GACH via emergency transportation services. A review of Resident 1's Order Summary Report, dated 10/21/2025, indicated transfer to ED via emergency transportation services due to high BS, ALOC, tachypnea, and shaking. A review of Resident 1's GACH Emergency Department (ED) Note, dated 10/21/2025 and timed at 1:33 a.m., indicated Resident 1 was sent to the GACH due to ALOC, hypotension and hyperglycemia. The Note indicated 10/21/2025 at 2:01 a.m., Resident 1's blood glucose level was 1824 mg/dl. The Note indicated Resident 1 was admitted with a diagnosis of DKA with coma and was intubated (a tube inserted into an individual's windpipe to help them breathe, usually in an emergency or for surgery to protect the airway). The Note indicated Resident 1 was started on an insulin drip (a medical treatment used in hospital critical care settings to rapidly and precisely manage severe high BS).During a concurrent interview and record review on 10/28/2025 at 3:26 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's 056433 Page 2 of 4 056433 10/30/2025 Vermont Healthcare Center 22035 S. Vermont Avenue Torrance, CA 90502

F 0684 Level of Harm - Actual harm Residents Affected - Few Order Summary Report dated 10/2025, the MAR dated 10/1/2025 to 10/31/2025, and the Progress Note dated 10/21/2025 were reviewed. RNS 1 stated Resident 1 was admitted to the facility with a diagnosis of DM and should have had his BS monitored daily. RNS 1 stated there should have been orders for BS monitoring and insulin administration as needed. RNS 1 stated there was no order to check Resident 1's BS but there should have been an order to check the BS and give insulin coverage as needed if the BS was high. RNS 1 stated if BS checks were not done, and the BS level was not controlled Resident 1, could go into hyperglycemic shock. During a telephone interview on 10/29/2025 at 10:37 a.m., with Resident 1's PCP, the PCP stated he was aware Resident 1 was a diabetic with a history of DKA. The PCP stated he was not aware Resident 1 did not have orders for BS monitoring. The PCP stated he was not aware Resident 1's BS was not checked from 10/13/2025 until 10/21/2025 when Resident 1 had to be transferred out to GACH due to hyperglycemia. During an interview on 10/29/2025 at 3:07 p.m., with the Director of Nursing (DON), the DON stated it was her responsibility to review all newly admitted residents' clinical documents including Resident 1, to ensure residents received the appropriate care and treatments. The DON stated facility staff should have checked Resident 1's BS at least four times a day with orders to administer insulin as indicated, when he was readmitted on [DATE]. The DON stated she should have clarified the orders with Resident 1's PCP to ensure Resident 1's DM was properly monitored for complications of hyperglycemia. The DON stated since BS checks and insulin were not administered when Resident 1's BS level was high, Resident 1 experienced ALOC, and was at risk for DKA, unconsciousness, and non-responsiveness. The DON stated it was the facility's responsibility to make sure residents with diagnosis of DM had BS checks and insulin orders in place. During a concurrent interview and record review on 10/30/2025 at 2:57 p.m., with RNS 2, Resident 1's care plan, titled Diabetes Mellitus Uncontrolled High BS Results dated 9/27/2025, was reviewed. RNS 2 stated Resident 1 had a diagnosis of DM, and the interventions on the care plan included to monitor Resident 1 for signs and symptoms of hyperglycemia, and to monitor the resident's BS. RNS 2 stated the facility did not implement Resident 1's care plan for DM. RNS 2 stated the staff did not check the resident's BS four times a day (before meals and at bedtime) and did not administer insulin to Resident 1 as needed per the sliding scale. RNS 2 stated any resident admitted with a diagnosis of DM should have orders for BS monitoring. RNS 2 stated a care plan was a plan on how to take care of residents. RNS 2 stated the care plan should be initiated and implemented according to each resident's diagnoses. RNS 2 stated a care plan outlined how staff should care for the residents, and If the care plan was not followed, it may lead to a negative outcome (hyperglycemia, DKA, coma) in the residents' condition. A review of the facility's undated policy and procedures (P&P) titled Diabetic Management and Insulin Administration, indicated to ensure safe, timely, and effective monitoring of blood glucose and administration of insulin in accordance with the physician orders and regulatory standards.A review of the facility's undated P&P titled, Comprehensive Plan of Care, indicated the facility will develop a comprehensive plan of care for each resident including goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs as identified during each resident's comprehensive assessment. The P&P indicated the care plan must describe services provided to the resident including interventions to attempt to manage risk factors; periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occurred,.re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment, quarterly, and with significant change in status assessment.A review of the facility's undated Job Description titled, RN Supervisor, indicated the RN supervisor will provide direct nursing care to the residents, and supervise the day-to-day nursing activities performed by the Licensed Vocational Nurse (LVN) 056433 Page 3 of 4 056433 10/30/2025 Vermont Healthcare Center 22035 S. Vermont Avenue Torrance, CA 90502

F 0684 Level of Harm - Actual harm Residents Affected - Few and certified nursing assistants (CNA). The job description indicated nursing care functions included consulting with the resident's physician in providing the resident's care, treatment, rehabilitation, as necessary, review the resident's chart for specific treatments, medication orders, diets, as necessary, implement and maintain established nursing objectives and standards, make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status, ensure that direct nursing care be provided by a licensed nurse and/or a certified nursing assistant, ensure that personnel providing direct care to residents are providing such care in accordance with the residents' care plan and wishes, review care plans daily to ensure that appropriate care is being rendered, inform the nurse supervisor of any changes that need to be made on the care plan, ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment. review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs, ensure that your assigned LVNs and CNAs are aware of the resident care plans.A review of the facility's undated job description titled, Director of Nursing Service/Vice President of Nursing Service, indicated the purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. assess resident needs and interview, set resident care standards in accordance with accepted current standards of care to provide high quality care to residents, develop and implement policies and procedures for nursing care of residents, supervise and manage all aspects of the nursing department, assess, direct and supervise residents' care needs.direct, evaluate and supervise all resident care and initiate corrective action as necessary.assess resident care needs and assist in the development of individualized plans of resident care. assess resident pre-admission and/or admission information and determine appropriate level of care.assess resident responses to medication and treatments and make appropriate recommendations for nursing action to be implemented.consistently make accurate level of care determinations, based on the physician's recommendations and the resident's plan of care. 056433 Page 4 of 4