Other·July 19, 2017

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 to investigate one complaint. Complaint Number: CA00537599 Representing the California Department of Public Health: 37379 34959 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00537599

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

F309 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 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: YFWW11 Facility ID: CA240000650 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 06/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 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, 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 interview, and record review, the facility failed to ensure that all tests and medications ordered at the time of admission were transcribed and administered to one of three sampled residents (Resident 1), when insulin (Insulin Aspart- controls blood sugar) and finger stick blood sugars were missed for a total of 10 days. This failure resulted in Resident 1 experiencing hyperglycemic hyperosmotic non- ketotic syndrome (HHNS) (a complication of high blood sugar state causing severe dehydration, increases in osmolality (relative concentration of solute) and a high risk of complications, coma and death. It is diagnosed with blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFWW11 Facility ID: CA240000650 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 06/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 tests), requiring an admission to the general acute care hospital (GACH 2). Findings: An unannounced on-site visit was conducted on June 1, 2017, for an abbreviated survey to investigate a complaint regarding Resident 1 being admitted to a GACH with a blood sugar greater than 900 (normal 70-110 milligram per deciliter (mg/dl)). During a review of Resident 1's electronic clinical record (e-record) the "Face sheet" (a document which provides the demographic data of the resident) indicated Resident 1 was admitted to the facility on May 17, 2017, at 7:45 PM, from a General Acute Care Hospital (GACH 1), with diagnoses which included: acute respiratory failure (a condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon dioxide becomes dangerously high), metabolic encephalopathy (brain disease caused by abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain functions) and diabetes mellitus Type 2 (DM 2-is a long term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and has a gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach). A review of the discharge orders from the transferring facility (GACH 1) dated May 17, 2017, for Resident 1, included, "Insulin Aspart, subcutaneous (under the skin) injection, units sliding scale (insulin dosed based on finger FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFWW11 Facility ID: CA240000650 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 06/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 stick blood sugar readings), if BS (blood sugar) < (less than) 50 milligram per deciliter (mg/dl) (a unit of measurement), critical value, notify MD (physician). If BS < 61, see D50 (50% Dextrose solution given to raise blood sugar) order. If BS 150 to 200, give 3 units [insulin]. If BS 201 to 250, give 5 units [insulin]. If BS 251 to 300, give 7 units [insulin]. If BS 301 to 350, give 9 units [insulin]. If BS 351 to 400, give 11 units [insulin]. If BS > (greater than) 400, Notify MD. If BS >450,critical value Notify MD. First dose (order initiated) 4/6/17(April 6, 2017) 0600 (6 AM), y Q6H (every six hours), last dose 5/17/17 ( May 17, 17) 7:08 AM." A review of Resident 1's "Order Summary Sheet," dated May 17, 2017, did not include the transfer order to continue the finger stick blood sugars with the sliding scale dose of insulin, as prescribed in the discharge orders from the transferring facility (GACH 1). During an interview with the Registered Dietician (RD) on June 13, 2017, at 2:10 PM, she stated that she was not informed about Resident 1's diabetic diagnosis. During an interview with a Registered Nurse (RN 1) on June 13, 2017 at 3:08 PM, she reviewed the e-record and was unable to find documentation of the medication verification with the physician upon admission for Resident 1. RN 1 described the admission order verification process as follows: when a new admission comes it is the licensed nurses' responsibility to call the physician and verify orders and document the verification in the residents' e-record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFWW11 Facility ID: CA240000650 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 06/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 An interview was conducted on June 13, 2017 at 3:14 PM, with the Licensed Vocational Nurse (LVN 1) who had entered the transfer orders into Resident 1's electronic clinical record. LVN 1 stated that she verified with Resident 1's physician regarding the admission orders via her personal cell phone. LVN 1 was unable to show the evidence of communication with the physician stating, "Those texts were accidently deleted from my phone." LVN 1 reviewed Resident 1's e-record and was unable to find any documentation of medication verification, or the order for the finger stick blood sugars nor insulin as ordered on the discharge transfer form from the GACH 1. A review of Resident 1's "Physician Progress Notes" written by Physician 2, dated May 19, 2017, indicated that Resident 1 had a history of DM 2 and the facility staff were to "...continue present discharge orders"[from GACH 1]. During a telephone interview with Physician 2, on June 16, 2017 at 11:55 AM, he stated that he did not receive any call or text regarding Resident 1's admission orders. He further stated that during his onsite visit with Resident 1, on May 19, 2017, he reviewed the discharge orders from the previous facility [GACH 1] for Resident 1 and recommended to continue the orders. During an interview with the Director of Nurses (DON), on June 13, 2017 at 2:22 PM, he stated that when a new admission comes into the facility, more than one licensed staff, and the physician review the orders. He was unable to explain how this medication order had been missed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFWW11 Facility ID: CA240000650 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 06/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 A review of Resident 1's Medication Administration Record (MAR) for the month of May 2017, indicated that Resident 1 did not have the finger stick blood sugar checks nor insulin orders reflected on the MAR. A review of Resident 1's clinical record titled "SBAR(Situation Background Assessment Recommendations)/ Acute Care Transfer" dated May 27, 2017, indicated that Resident 1 required a transfer to the acute care hospital (GACH 2) due to shortness of breath. A review of the admission assessment from GACH 2 dated May 27, 2017, indicated that Resident 1 was admitted for "Hyperglycemia" (high blood sugar). Further review of the clinical record indicated that Resident 1 was in a state of severe dehydration due to HHNS. Resident 1 was being treated in GACH 2 with a continuous insulin drip (intravenous administration of insulin) for hyperglycemia. A review of the of the clinical laboratory results for Resident 1, from GACH 2, dated May 27, 2017, indicated that the blood sugar level was 949 mg/dl where the normal range was 70-110 mg/dl.(unit of measure). A review of the skilled nursing facility's policy and procedure titled "Reconciliation of Medication on Admission," revised December 2012, indicated: "The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission." The policy further indicated that licensed nurses were required to communicate with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFWW11 Facility ID: CA240000650 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: _______________ 555350 (X3) DATE SURVEY COMPLETED 06/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MADISON GROVE POST ACUTE 1618 Laurel Ave Redlands, CA 92373 (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 physician for medication reconciliation and document that in the residents' medical record on admission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YFWW11 Facility ID: CA240000650 If continuation sheet 7 of 7