Health inspection·July 25, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm 3. Insulin Lispro (medicine for DM) to be injected per sliding scale (the amount of insulin to be administered would depend on the BS level ) before meals and at bedtime. If BS is less than 60 milligrams per deciliter ([mg/dl] unit of measurement), give Glucagon (a hormone that pancreas makes to help regulate blood glucose (sugar) levels and increases blood sugar levels, preventing it from dropping too low) 1 mg IM and call the MD. Residents Affected - Few 4. Glipizide (medicine for DM) oral tablet extended release 24-hour 10 milligram ([mg] a unit of measurement), one (1) tablet by mouth twice a day before breakfast. 5. Januvia oral tablet 50 mg. (medicine for DM), 1 tablet twice a day. During a concurrent interview and record review on 7/25/2024 at 2:34 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's progress notes dated 1/24/2024 at 3:52 p.m. were reviewed. LVN 1 stated the notes indicated Resident 1 had a blood sugar level of 55 (time not specified), however, the progress notes did not indicate the MD was notified of the BS level of 55 mg/dl as per physician's order. LVN 1 stated the licensed nurse should have administered glucagon to Resident 1 due to BS level of 55 mg/dl. LVN 1 stated the BS level should have been reported to MD because if resident have not received glucagon, Resident 1's blood sugar would have dropped lower. During a concurrent interview and record review on 7/25/2024 at 3:42 p.m. with Registered Nurse (RN) Supervisor 1, Resident 1's Medication Administration Record (MAR) dated January 2024 was reviewed. The RN Supervisor stated the MAR on 1/24/2024 at 11:30 a.m., indicated Resident 1 had a BS level of 55 mg/dl. The RN Supervisor stated MAR did not indicate Glucagon 1 mg. was administered to Resident 1 as indicated in the MD order which indicated to administer Glucagon 1 mg. IM if BS was less than 60 mg/dl. During a review of Resident 1's Nursing Progress Notes dated 1/24/2024, the progress notes dated 1/24/2024 at 10:44 p.m. indicated Resident 1 was on a clear liquid diet. The progress notes indicated blood sugar was monitored. During a review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured way to communicate to the care team about a resident's change in condition) dated 1/25/2024 at 12:32 a.m., the SBAR indicated a Certified Nurse Assistant (CNA) called for help in Resident 1's room on 1/24/2024 at 11:41 p.m. The SBAR indicated Resident 1 was nonverbally responsive, awakened when touched, heart rate was 48 beats per minute (normal 60-100 beats per minute), oxygen saturation (the amount of oxygen in the bloodstream with normal range of 95-100%) was 88 percent (%) on room air (without use of oxygen). The SBAR indicated oxygen via simple mask was administered and 911 (emergency phone number) was called. The SBAR indicated Resident 1 was transferred to general acute care hospital (GACH) on 1/25/2024 at 12 midnight. During an interview on 7/26/2024 at 2:26 p.m. with the Director of Nursing (DON), the DON stated the facility should have given Resident 1 the Glucagon 1 mg IM as ordered, rechecked the blood sugar level and notified the MD. The DON stated if MD was not notified of the blood sugar level of 55 mg/dl., corrective actions could not be received. The DON stated, administering glucagon is part of a nursing intervention and is part of change of condition. During a review of the facility's Nursing Manual – Dietary & Dining titled, Hypoglycemia, dated 1/1/2012, the manual indicated residents on hypoglycemic medications should be monitored for signs and symptoms of hypoglycemia during routine daily basis. The manual indicated, unless otherwise (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056478 If continuation sheet Page 2 of 3 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 056478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lighthouse Healthcare Center 2222 Santa Ana Blvd. Los Angeles, CA 90059 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documented on the MAR per attending physician order, the nurse should notify the attending physician of any blood sugar levels of below 70 mg/dl. During a review of the facility's undated P&P titled, Change of Condition Notification, the P&P indicated the facility should promptly consult with the resident's attending physician when a resident has a significant change in condition. The P&P indicated the facility should immediately call the attending physician in emergency situations. Event ID: Facility ID: 056478 If continuation sheet Page 3 of 3