Other·May 7, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint conducted on 5/1/18. For Complaint CA00580385 regarding Quality of Care/Treatment, a federal deficiency was identified (see F684). A Class "B" Citaion was issued. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 35386, Health Facilities Evaluator Nurse

F684 SS=G Quality of Care CFR(s): 483.25

F684 05/31/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure nursing staff verified a physician's order prior to administering excessive insulin (a medication used to lower blood sugar) for one of four residents (Resident LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0UD11 Facility ID: CA070000074 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 05/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1) and monitored Resident 1's blood sugar every 30 minutes as ordered after administering the excessive dose of insulin. This failure resulted in Resident 1 developing hypoglycemia (a condition caused by a very low level of blood sugar) and unnecessary hospitalization. Findings: Review of Resident 1's Progress Notes, dated 3/26/18, indicated Resident 1 was admitted to the facility on 3/26/18 with diagnoses of end stage renal disease (kidney and organs that remove waste from the blood have stopped working) with kidney transplant (surgical operation to replace the organ that removes waste from the blood) and diabetes mellitus (DM, a chronic condition associated with abnormally high levels of sugar in the blood). Review of Resident 1's Discharge Summary from an acute care hospital, dated 3/26/18, indicated insulin glargine (Lantus) (a type of insulin, used for blood sugar control) "100 units/mL (units per milliliter (mL, a unit of volume)) (3 mL)". The order included a concentration (the strength of a solution, the amount of dissolved substance in a given volume) of the insulin and did not include the specific dosage to administer. Review of Resident 1's Medication Administration Record (MAR), dated 3/26/18 at 9 p.m., indicated Lantus 100 unit/mL and the "Amount to Administer" was 3 mL. It indicated licensed vocational nurse A (LVN A) administered 3 mL (300 units) of Lantus to Resident 1. Review of Resident 1's Progress Notes, dated 3/27/18 at 6:50 a.m., indicated registered nurse C (RN C) received a report from LVN A and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0UD11 Facility ID: CA070000074 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 05/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE notified an on-call doctor regarding administration of 300 units of insulin. The doctor ordered to monitor the resident's blood sugar (BS) every 30 minutes to maintain the BS level at 90 mg/dL (milligrams per deciliter, a unit of measurement of blood sugar, the normal BS ranges from 72 to 99 when fasting) and administer a glucose gel tube (an over-thecounter medication used to raise blood sugar) when the BS went below 90 mg/dL. Review of Resident 1's physician's order indicated no orders for blood sugar monitoring every 30 minutes and glucose gel administration when the blood sugar went below 90 mg/dL. Review of Resident 1's blood sugar monitoring indicated Resident 1's BS was checked four times on 3/27/18. The results were 172 mg/dL at 6:44 a.m., 82 mg/dL at 10:56 a.m., 97 mg/dL at 5:30 p.m., and 111 mg/dL at 7:30 p.m. There was no documented evidence the resident's BS was monitored every 30 minutes as ordered or staff contacted the physician to adjust the BS monitoring orders. A review of Resident 1's Progress Notes, dated 3/27/18 at 2:45 p.m., indicated LVN A documented Resident 1's BS was above 90 mg/dL during her shift even though it was 82 mg/dL at 10:56 a.m. There was no documented evidence a glucose gel tube was administered as ordered. Review of Resident 1's Progress Notes, dated 3/28/18, indicated at 3:40 a.m., Resident 1's BS was 65 mg/dL and LVN D gave Resident 1 some snack and juice per Resident 1's request, instead of a glucose gel tube as ordered. It indicated at 5:20 a.m. during the rounding, Resident 1 was diaphoretic and hard to arouse, verbalized she felt nauseated and "terrible and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0UD11 Facility ID: CA070000074 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 05/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE scared", and the BS was 55 mg/dL. At 5:49 a.m., Resident 1's BS was 58 mg/dL and the nurse called 911 at 5:55 a.m. Review of Resident 1's Discharge & TransferHospital Transfer Form, dated 3/28/18, indicated Resident 1 was lethargic (sleepy), unresponsive (not responding), diaphoretic (sweating), nauseated (queasy), and shaking. It indicated Resident 1 was experiencing fluctuating blood sugars, the nurse was unable to raise Resident 1's blood sugar, and Resident 1 was transferred to the emergency department (ED) in an acute care hospital. Review of Resident 1's ED Evaluation from the acute care hospital, dated 3/28/18, indicated Resident 1's laboratory glucose (sugar) level was 25 mg/dL when she arrived in the ED. It indicated Resident 1 received 300 units of insulin as opposed to the normal 20 units and "there was 3 mL noted but what that basically said was 3 ml in the pen, not 3 mL to be given." The impression was persistent hypoglycemia secondary to accidental insulin overdose. Review of Resident 1's Transfer Summary from the acute care hospital, dated 3/31/18, indicated Resident 1 was discharged from an acute care hospital to a skilled nusing facility with a diagnosis of iatrogenic (a disorder induced inadvertently caused by medical treatment) hypoglycemia due to excessive insulin. During an interview on 4/9/18 at 3:18 p.m., LVN A acknowledged she administered 300 units of Lantus insulin to Resident 1 on 3/26/18 at bedtime and she stated that was a lot of insulin. LVN A stated on 3/26/18 she went to her supervisor, RN B, for clarification of the order before administering the insulin. LVN A stated RN B was busy and she brushed her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0UD11 Facility ID: CA070000074 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 05/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE away. She stated she drew 3 mL insulin into three insulin syringes containing 1 mL (100 unit) each and administered them to Resident 1. LVN A stated she should have clarified the insulin order with Resident 1's attending physician before she administered the insulin. During an interview with RN B, the nursing supervisor, on 4/9/19 at 3:45 p.m., she stated she told LVN A she was not comfortable with that amount of insulin and to clarify the order with Resident 1's attending physician. RN B stated 300 units were not an order to administer. During an interview with the ward clerk, on 4/9/18 at 4:13 p.m., she stated she transcribed Resident 1's Lantus insulin order from a discharge summary to the MAR. She stated licensed nurses had to verify the orders. During an interview with RN C on 4/18/18 at 8:40 a.m., he stated during a change-of-shift report, LVN A told him she administered 300 units of Lantus insulin to Resident 1. RN C stated he reported the insulin administration to an on-call doctor and the doctor ordered to monitor Resident 1's BS every 30 minutes to keep her BS above 90 mg/dL, and to give a glucose gel tube if her BS went below 90 mg/dL. RN C stated he checked Resident 1's BS every 30 minutes during his shift but did not document it in Resident 1's clinical record. RN C stated he was unsure if he wrote a verbal order. During an interview on 4/9/18 at 2:45 p.m. with LVN D, who transferred Resident 1 to the hospital on 3/28/18, she stated she did not perform the 30-minute BS monitoring during her shift and did not administer a glucose gel tube when Resident 1's BS went below 90 mg/dL because there were no orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0UD11 Facility ID: CA070000074 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 05/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 4/18/18 at 2:20 p.m., the director of nurses (DON) reviewed Resident 1's clinical record and stated there were no orders written to monitor Resident 1's BS every 30 minutes and administer a glucose gel tube when the resident's BS went below 90 mg/dL. She stated RN C should have written a doctor's order. She stated there was no documented evidence Resident 1's BS monitoring was done as ordered. During an interview on 4/18/18 at 2:40 p.m., LVN A stated she checked Resident 1's BS twice during her shift on 3/27/18. She stated she did not monitor Resident 1's BS every 30 minutes because there was no order. Review of the facility's 6/2015 policy, "NONCONTROLLED MEDICATION ORDER DOCUMENTATION", indicated medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders for noncontrolled medications are received only by licensed nurses or pharmacists and confirmed in writing by the prescriber. To facilitate effective communication, documentation, and aid in preventing of medication errors, medication orders should be clear and concise. Medication orders specify strength of medication and dose. Any dose or order that appears inappropriate is verified by nursing with the attending physician and unsigned written transfer orders sent with a resident by a hospital should be verified with the current attending physician before medications are administered. Review of the facility's 9/2014 policy, "Insulin Administration", indicated the type of insulin, dosage requirements, strength, and method of administration must be verified before FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0UD11 Facility ID: CA070000074 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 05/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administration. Review of the facility's 2/2014 policy, "Verbal Orders", indicated the individual receiving the verbal order must write it on the physician's order sheet as "v.o." (verbal order) or "t.o." (telephone order). Review of the facility's 12/2012 policy, "Administering Medications", indicated if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0UD11 Facility ID: CA070000074 If continuation sheet 7 of 7