Other·September 14, 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 an Abbreviated Standard Survey for Complaint # CA 00518672 . Inspection was limited to the Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor #35362, Health Facilities Evaluator Nurse. One deficiency at F 309 was issued for Complaint # CA00518672.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 08/15/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 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 personLABORATORY 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: P2H811 Facility ID: CA010000046 If continuation sheet 1 of 8 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: _______________ 555161 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (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 centered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interviews and record reviews, the facility failed to a) clarify incomplete physician orders for Resident 1's diabetic medication, b) follow nursing practice standards to not administer the diabetic medication and call the MD for further instructions, c) assess Resident 1's blood glucose when he acted irrational by attempting to stab himself. The facility therefore failed to provide the necessary care and services to maintain one (Resident 1) of 16 residents with diabetes (a chronic condition that affects the way the body uses sugar (glucose) highest level of well-being. This failed practice resulted in harm to Resident 1 and had the potential to cause harm and possible death to all residents diagnosed with diabetes. Findings: On 01/18/17, the Department received a complaint alleging Resident 1 had been admitted to a local hospital on 01/05/17 after Resident 1 attempted "to stab (him)self with a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P2H811 Facility ID: CA010000046 If continuation sheet 2 of 8 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: _______________ 555161 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (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 fork." Resident 1's blood sugar in the Emergency Room on 01/05/17 had been 14 mg/dL. Resident 1 died on 01/08/17. Review of a document titled "Resident Face Sheet" revealed Resident 1 was a 69 year old male who had been admitted to the facility on 12/31/16. Resident 1 had, among others, the diagnoses of "Severe Sepsis (infection of the blood) with Septic Shock" (Septic Shock is a significant drop in blood pressure due to infection in the blood that can lead to organs failure and death)," dependence on renal dialysis" (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney), "type 2 diabetes mellitus" (a disease in which the body does not make enough insulin or does not correctly use the insulin it does make. When eating, the body breaks down all sugars and starches into glucose. The body needs insulin to use glucose for energy), "long term and current use of insulin" (hormone that is needed to allow the body to utilize glucose as a fuel for the body and the brain; occurs naturally in the body or is given in form of medication for persons with diabetes). Resident 1 did not have diagnoses of mental health disorders. Review of a facility document titled "Diabetic Management Administration History: 01/01/2017-01/26/2017" revealed under section "Order" on page 1 "Humulin 70/30 (insulin nph (Neutral Promanine Hagedorn) (70%) (intermediate acting (onset 1.5-4 hours) and regular (30%) (short acting (onset 30 min-1 hour) human) [OTC] (over the counter) suspension; 100 units/mL (milliliter) (70-30); amount to administer: 25 units; subcutaneous (under the skin)." The frequency indicated "once per day before breakfast." The document revealed Resident 1's blood sugar on 01/05/17 at 07:30 (7:30 a.m.) was 71 mg/dL. Page 3 of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P2H811 Facility ID: CA010000046 If continuation sheet 3 of 8 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: _______________ 555161 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (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 the document revealed under "Order" "Lantus (insulin glargine) (a long acting (onset 0.8-4 hours) insulin) solution; 100 units/ml; Amount to Administer: 14 units; subcutaneous." The physician order did not contain parameters of when the insulin was to be held and Resident 1, with a blood sugar of 71mg (milligram) (a unit of measurement) was administered the insulins. Both insulins were signed as administered by Licensed Staff B on 01/05/17 at 7:30 a.m. Review of a facility document titled "Diabetic Management Administration History" revealed Resident 1 was given 25 units of one and 14 units of another type of insulin via injection before breakfast. (Insulin is given within 15-30 minutes before a meal. Insulin breaks down the food so it can be used as energy). Resident 1's blood sugar (level of sugar in the blood) was 71 mg/dL (milligram per deziLiter (tenth of a Liter)) (normal range for person with diabetes 80-130 mg/dL (recommendation by the American Diabetic Association) before the two types of insulin were administered. During an interview and concurrent record review on 03/09/17 at 2:05 p.m., Management Staff A (a licensed nurse in a management position) confirmed on 01/05/17 at 0750 (7:50 a.m.) Licensed Staff B had administered 2 types of insulin to Resident 1 according to the Medication Administration Record. Management Staff A stated according to the Medication Administration Record, Resident 1's blood sugar had been 71 mg/dL. Management Staff A confirmed the Medication Administration Record did not reflect a hold parameter for the insulin. Management Staff A stated he would "expect (nurses) to hold (not administer) (the insulin) and call the MD" if the blood sugar was "below 80 mg/dL." Management Staff A stated that nurses usually FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P2H811 Facility ID: CA010000046 If continuation sheet 4 of 8 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: _______________ 555161 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (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 got the parameters (low blood sugar reading when to hold the insulin and notify the physician, and high blood sugar reading when to notify the physician) clarified by the physician. Management Staff A stated any nurse could clarify the parameters. Management Staff A stated anyone who had a sudden change in condition, like Resident 1, should have had their blood sugar checked, especially a resident diagnosed with diabetes. During an interview on 03/09/17 at 2:22 p.m. Licensed Staff C stated she had been involved in sending Resident 1 to a local hospital on 01/05/17 due to Resident 1 attempting to stab himself with a fork. Licensed Staff C stated she had not been aware Resident 1 was diagnosed with diabetes. Licensed Staff C stated she had not been made aware Resident 1 had received 2 types of insulin and refused to consume his breakfast prior to the episode of attempting to stab himself with a fork. Licensed Staff C confirmed the nurse's notes written by Licensed Staff C on 01/05/17 did not include a blood sugar check before Resident 1 was sent to a local hospital. During an interview on 03/09/17 at 2:45 p.m., Licensed Staff B confirmed administering two types of insulin via injection to Resident 1 in the morning of 01/05/17. Licensed Staff B confirmed Resident 1's blood sugar had been 71 mg/dL. Licensed Staff B stated Resident 1 had acted "loopy" (confused) before receiving the insulin doses. Licensed Staff B stated there had been no parameter when to hold the insulins, and therefore she had given the insulins. Licensed Staff B stated the admission nurses, who clarified admission orders on the first day a resident was admitted, entered the orders including the parameter into the system. When asked who could clarify the orders or obtain the hold parameter, Licensed Staff B FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P2H811 Facility ID: CA010000046 If continuation sheet 5 of 8 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: _______________ 555161 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (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 stated she did not know. Licensed Staff B stated she was not comfortable entering orders into the computer system. Licensed Staff B confirmed Resident 1's blood sugar was not checked prior to being sent to a local hospital on 01/05/17. Licensed Staff B confirmed there was no progress note written by Licensed Staff B on 01/05/17 regarding Resident 1 attempting to stab himself with a fork and being sent to a local hospital. Review of a facility document titled "Vitals Report" dated 01/05/17 at 10:06 a.m., revealed two identical entries for "Breakfast" by Unlicensed Staff D "Not taken: Refused." Resident 1 refused to eat his breakfast after receiving the two types of insulin. (Not eating a meal after receiving insulin could drop blood sugars to a critical level). Review of a facility document titled "Event Report" dated 01/05/17 at 11:46 a.m., revealed the Physician order: "Transfer patient to ER (emergency room) for psych. (psychiatric) Eval (Evaluation)." The document revealed "...patient's vital signs are currently stable" the vital signs taken (102/60 (Blood pressure); 78 (Pulse); 19 (Respirations); 98.7 (Temperature); 93% (Oxygenation of the blood) RA (Room Air)). (The vital signs taken did not include Resident 1's blood sugar). Resident 1's Care Plans, provided by the facility on 01/26/17, did not include a Care Plan for Diabetes Mellitus. There were no goals or interventions listed for how to care for Resident 1 in regards to his diagnosis of Diabetes Mellitus. Review of a hospital document titled "History and Physical" dated 01/05/17 at 18:30 PST (6:30 p.m. Pacific Standard Time) revealed under "Chief Complaint" "Patient presents with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P2H811 Facility ID: CA010000046 If continuation sheet 6 of 8 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: _______________ 555161 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (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 hypoglycemia (low blood sugar)." The document revealed under section "History of Present Illness..."In the ED (Emergency Department) he was found to be hypoglycemic to 14 (critical levels are < (less than)50 mg/dl (Lexicomp online)". The document revealed under section "Results Review: Lab results: Lab" dated 01/05/17 at 12:23 PST "POCT (Point of Care Testing) (a glucometer) -Glucose (Capillary) 14 mg/dL CRIT (critical), Interpretation Abnormal Results Hypoglycemia ...." The document revealed under section "Reexamination/Reevaluation: Course: resolved. Altered mental status 2/2 (secondary to) (due to) hypoglycemia", and under "assessment" Exam improved, patient no longer altered mental status after receiving IV (intravenous) D50 (liquid sugar solution) and he ate lunch to prevent relapse of hypoglycemia." Review of the facility Policy and Procedure titled "Nursing Care of Resident with Diabetes Mellitus" dated 2001, revised April 2009, revealed as "Purpose" ...3. Prevent recurrent hyperglycemia/hypoglycemia 4. Recognize, manage, and document the treatment of complications commonly associated with diabetes, ...The document reveals under "Glucose Monitoring" ...4. b. Normal Ranges are approximately 90-130 mg/dl before meals and <180 mg/dl after meals,... and 5.a. Mild hypoglycemia 55-70 mg/dl. The document reveals under section "Conditions associated with Diabetes...3. Hypoglycemia (blood sugar below reference range). Signs and Symptoms of hypoglycemia usually have a sudden onset and may include the following...f. irritability or bizarre changes in behavior.... Review of "Lippincott Manual of Nursing Practice", 9th edition, published 2010 by Wolters Kluwer Health, Chapter 25 "Diabetes Mellitus" page 958 revealed under FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P2H811 Facility ID: CA010000046 If continuation sheet 7 of 8 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: _______________ 555161 (X3) DATE SURVEY COMPLETED 04/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NAPA VALLEY CARE CENTER 3275 Villa Ln Napa, CA 94558 (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 "Hypoglycemia Unawareness" "Patients may exhibit irrational thought,..." Under the Section "Standard of Care Guidelines" the Manual reveals "Assess for signs of hypoglycemia: ...confusion." Review of "Essentials of Medical-Surgical Nursing", Susan C. deWit, fourth edition, 1998, reveals in Chapter 25 "Care of Patients with Endocrine Disorders: Diabetes Mellitus and Hypoglycemia" p.818 "Nursing Assessment and Intervention: One of the most unfortunate consequences of hypoglycemia from any cause is that the physiological symptoms may be mistaken for indications of psychiatric illness. These symptoms include irritability, personality change ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P2H811 Facility ID: CA010000046 If continuation sheet 8 of 8