Other·March 14, 2024

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 the investigation of one complaint. Complaint number: CA00711726. Representing the California Department of Public Health, Surveryor 34388, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Four deficiencies were issued for complaint number CA00711726.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 04/17/2021 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). 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: 8WX011 Facility ID: CA240000148 If continuation sheet 1 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to notify the physician that one of seven sampled residents (Resident A) failed to receive the ordered medication insulin (medication that lowers the level of glucose [sugar] in the blood) after admission to the facility. This failure caused the resident's blood sugar to rise throughout the night, which necessitated Resident A to be sent out via 911 to the acute care hospital in the morning where she expired shortly after arrival to the hospital's emergency room (ER). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 2 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 Findings: On December 3, 2020, at 11:20 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment. On December 3, 2020, a review of Resident A's facility electronic medical record was conducted. Resident A was admitted to the facility on October 12, 2020, with diagnoses that included pyelonephritis (inflammation of the kidney due to a bacterial infection), hemiplegia and hemiparesis following a cerebral infarction (paralysis and or weakness of one side of the body following a stroke), essential hypertension (high blood pressure), and insulin dependent type 1 diabetes (disease in which the body does not make enough insulin to control blood sugar levels). Review of a document for Resident A titled, "SNF (skilled nursing facility) Supplemental Orders," dated, October 12, 2020, indicated, "Patient is NOT capable of giving informed consent and/or is unable to participate in the treatment plan." Further review of Resident A's facility medical record included a copy of the discharging hospital's Medication Administration Report (MAR), dated, October 12, 2020. This MAR documented the time of each medication Resident A received prior to discharge from the hospital to the facility on October 12, 2020. The MAR indicated the following: - "insulin glargine (Lantus) (medication to control high blood sugar) inject 17 units Dose: 17 units Freq: (frequency) 2 times daily Route: SubQ (subcutaneously-under the skin by injection)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 3 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 MAR indicated the resident received a dose at 9:31 a.m. and was to receive the next dose at 9:00 p.m., on October 12, 2020. A review of Lexicomp, a nationally recognized drug reference indicated, "Insulin glargine (Lantus) is used to lower blood sugar in patients with high blood sugar (diabetes) and is a long-acting insulin. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision. Insulin glargine must be used concomitantly (in combination) with rapid or short-acting insulins i.e., multiple daily injection regimen." - "insulin lispro (HumaLOG, ADMELOG) Inject 8 Units Dose: 8 units Freq: 3 times daily before meals Route: SubQ Admin (administration) Instructions: Give within 15 min (minutes) prior to meal..." Further review of Lexicomp indicated, "Insulin lispro (Humalog) is a rapid-acting insulin analog...Insulin requirements vary dramatically between patients and dictate frequent monitoring and close medical supervision. Diabetes mellitus, type 1, treatment: SubQ: Insulin lispro must be used concomitantly with intermediate or long-acting insulin." The hospital MAR indicated Resident A received a dose at 7:47 a.m., and 11:47 a.m., and was scheduled to receive the last dose at 5:30 p.m., on October 12, 2020. Review of Resident A's facility document titled, "Order Summary Report," indicated the following order dated October 12, 2020: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 4 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 - "Admit to (initials of facility) 10/12/2020 under the services of (name of doctor) with the following Dx (diagnosis)...Insulin dependent Type 1 DM (diabetes mellitus)..." Further review of Resident A's facility document titled, "Order Summary Report," indicated two orders for the insulin Humalog dated October 12, 2020: - "HumaLOG solution 100 Unit/ML (milliliter) (Insulin Lispro) Inject 8 unit subcutaneously before meals for diabetes mellitus give within 15 minutes prior to meal. Hold if not eating > (greater than) 25% of meals," and - "HumaLOG Solution 100 Unit/ML (Insulin Lispro) Inject 8 units subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals." Review of Resident A's facility document titled, "Order Summary Report," indicated an order, dated October 12, 2020, for, "Lantus Solution 100 Unit/ML (insulin glargine) Inject 17 unit subcutaneously two times a day for diabetes mellitus." Review of Resident A's "Admission Summary," dated, October 12, 2020, at 6:40 p.m., indicated, "Admitted to (initials of facility) at 2pm 10/12/2020, this 67 yo (sic) (year old) lady from (name of discharging hospital) under the service of (doctor's name)...Resident is alert, able to make needs known, not in respiratory distress...Resident ate 25% for supper...(name of doctor) made aware of this admission..." A review of Resident A's facility document titled, "Admit/Re-Admit Nursing Evaluation," dated, October 12, 2020, indicated, "Verification: 1. Attending Physician Notified, Orders Read FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 5 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 Back and Verified? a. Yes 2. If Yes, Indicate Date and Time of Notification, Orders Verification: 10/12/2020." Review of Resident A's facility care plans indicated the following care plan dated, October 12, 2020, "Focus- The resident has Diabetes Mellitus Type 1...Goal- The resident will be free from any s/s (signs or symptoms) of hyperglycemia (high levels of sugar in the blood) through the review date...The resident will have no complications related to diabetes through the review date. Interventions...Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness...Educate regarding medications and importance of compliance..." A review of Resident A's facility MAR indicated that the physician ordered insulin Humalog for 4:45 p.m. administration on October 12, 2020, was not given. Further review of the facility MAR for Resident A indicated the physician ordered administration of Lantus Solution scheduled for 9:00 p.m. on October 12, 2020, was not given. The record indicated that Resident A failed to receive any physician ordered insulins on October 12, 2020, after admission to the facility. A review of Resident A's facility "Progress Notes," indicated the following entry dated, October 12, 2020, at 9:38 p.m., "OrdersAdministration Note: Lantus Solution 100 Unit/ml. Inject 17 unit subcutaneously two times a day for diabetes mellitus. New admit, awaiting pharmacy for delivery will endorse." This progress note was authored by a license vocation nurse (LVN 1). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 6 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 Further review of Resident A's facility "Progress Notes," indicated the following entry dated, October 13, 2020, at 6:33 a.m., "Heath Status Note...Resident remains alert, oriented and verbally responsive. Able to make needs known...No adverse drug reactions noted at this time. No n/v (nausea and vomiting)..." A review of Resident A's MAR for October 13, 2020, indicated that the physician ordered administration of the insulin Humalog scheduled for 6:45 a.m., was not given. Further review of Resident A's facility "Progress Notes," indicated the following entry, "OrdersAdministration Note," dated, October 13, 2020, at 10:03 a.m., "HumaLOG Solution 100 Unit/ml. Inject 8 unit subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals (sic) resident vomited all she ate." A review of Resident A's MAR for October 13, 2020, indicated that no physician ordered administration of the insulin Humalog was administered on October 13, 2020. Further review of Resident A's facility medical record found no documentation that indicated the resident's physician was notified that the ordered insulins had not been given on October 12th or 13th. A review of Resident A's facility "Progress Notes," indicated the following entry, "Health Status Note," dated, October 13, 2020, at 11:30 a.m., "At 10:17 this morning resident was noted to be sweating and breathing fast. She was able to respond to her husband who was on the phone at the time. Blood sugar was checked and showed "HI". CNA (certified nursing assistant) reported to this writer earlier that resident vomited breakfast food (sic)... (name of doctor) and husband FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 7 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 informed...Husband was updated of residents' (sic) condition and at 10:54am (sic) agreed that resident be transferred to hospital preferably to (name of discharged hospital). Call to 911 was placed and they arrived about 11:15. This writer went to check on the resident at about this time and found her to be unresponsive (unconscious, possibly dead or dying)...Resident was transferred out of the facility around 11:25am (sic)." On December 28, 2020, at 3:09 p.m., a phone interview was conducted with a licensed vocational nurse (LVN 2). LVN 2 confirmed that he had provided care for Resident A on the morning of October 13, 2020. LVN 2 was asked if he had administered the physician ordered insulins during his shift. LVN 2 stated that he could not remember exactly which insulin he had given, but stated after the doctor was notified, he believed that he had given the Lantus. LVN 2 continued that his supervisor had contacted the doctor to get an order to check the resident's blood sugar level. LVN 2 stated that when he checked the blood glucose monitor it kept reading, "high." A review of the leading provider of blood sugar monitoring systems, "Accu-Chek" indicated, "If the letters HI are displayed on the screen, the blood glucose may be higher than the measuring range of the system. The meter is designed to provide a numerical value for blood glucose in the range of 20-600 mg/dL (milligram/deciliter)." On December 29, 2020, at 4:07 p.m., a phone interview was conducted with Resident A's attending physician (AP) at the facility. The AP was asked if she had been notified that Resident A had failed to receive her ordered insulins October 12th and October 13th. The AP stated that she had not been notified that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 8 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 resident had not received her medications. The AP continued that she does not "always get notified for things like that." On December 30, 2020, at 10:16 a.m., a phone interview was conducted with the facility's Director of Nursing (DON). The DON was asked the facility's expectation to notify the physician if medications were not available to be given at the ordered time. The DON stated that if medications were not delivered or not available to be given, the staff should have called the physician and informed the physician that the medications were late or not available to get new orders. On December 30, 2020, at 10:30 a.m., a phone interview was conducted with LVN 1. LVN 1 confirmed that she had provided care for Resident A on October 12, 2020. LVN 1 stated she had worked a double shift that day from 6:30 a.m. to 11:00 p.m. LVN 1 was asked if she had administered Resident A's insulins. LVN 1 stated, "no." LVN 1 further stated that the medications had not been delivered from the pharmacy to the facility during her shift. LVN 1 continued that she had not had the medications at that time to administer. LVN 1 was asked if she had called to inform the physician that the medications were not available to give. LVN 1 stated, "I didn't call personally." LVN 1 stated that she was unaware if anyone had called the physician to notify them that the medications were not available to give at the ordered times. LVN 1 was then asked if it was expected for the physician to be notified if a medication was not available to be given at the ordered time. LVN 1 stated, "yes," it would be expected to have notified the physician. Review of a facility policy titled, "Drug Ordering and Receipt," undated, indicated, "...10. If the ordered medication is not available from the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 9 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 pharmacy, the pharmacy will call the nurse on duty with an explanation, as well as alternative medications that can be used instead. The physician is then to be called for an order change to ensure that the resident receives the necessary medication. Under no circumstances should there be missed doses of medications due to the drug(s) "not being available from the pharmacy..."

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

F684 04/17/2021 § 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 that one of seven sampled residents (Resident A) received necessary treatment and care in accordance with professional standards of practice. This failure occurred when the facility: 1. Did not ensure Resident A received the physician ordered insulin (medication that lowers the level of glucose [sugar] in the blood) after admission to the facility, and 2. Did not provide Resident A with necessary blood sugar monitoring. These failures resulted in Resident A's unmonitored and uncontrolled blood sugar to rise throughout the night, which necessitated Resident A to be sent out via 911 to the acute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 10 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 care hospital in the morning where she expired shortly after arrival at the hospital's emergency room (ER). Findings: On December 3, 2020, at 11:20 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment. On December 3, 2020, a review of Resident A's facility electronic medical record was conducted. Resident A was admitted to the facility on October 12, 2020, with diagnoses that included pyelonephritis (inflammation of the kidney due to a bacterial infection), hemiplegia and hemiparesis following a cerebral infarction (paralysis and or weakness of one side of the body following a stroke), essential hypertension (high blood pressure), and insulin dependent type 1 diabetes (disease in which the body does not make enough insulin to control blood sugar levels). Review of a document for Resident A titled, "SNF (skilled nursing facility) Supplemental Orders," dated, October 12, 2020, indicated, "Patient is NOT capable of giving informed consent and/or is unable to participate in the treatment plan." A review of a record for Resident A from the discharging hospital titled, "Physician Discharge Summary," dated October 12, 2020, indicated, "Discharge Medications: -insulin glargine 100 unit/mL (milliliter) injection Commonly known as LANTUS. Instructions: Inject 0.17 mLs (17 Units total) into the skin 2 (two) times daily. Dose: 17 Units What changed: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 11 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 *how much to take *how to take this *when to take this *additional instructions" A review of Lexicomp, a nationally recognized drug reference indicated, "Insulin glargine (Lantus) is used to lower blood sugar in patients with high blood sugar (diabetes) and is a long-acting insulin. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision. Insulin glargine must be used concomitantly (in combination) with rapid or short-acting insulins i.e., multiple daily injection regimen." "-insulin lispro 100 unit/mL injection Commonly known as: HumaLOG Instructions: Inject 8 units subcutaneously (under the skin) TIDAC (Three times a day before meals) meals if eating > (greater than) 25% of meal. What changed: additional instructions -insulin lispro 100 unit/mL injection Commonly known as: HumaLOG Instructions: Inject 0-5 units three times daily before meals as needed per sliding scale: BG (blood glucose) <70 = hold rapid-acting insulin and see hypoglycemia (low blood sugar) measures. 70-150 = No correction 151-200 = 1 unit, 201-250 = 2 units, 251-300 = 3 units, 301350 = 4 units, > 350 = 5 units and notify provider on call. What changed: You were already taking a medication with the same name, and this prescription was added. Make sure you understand how and when to take each..." Further review of Resident A's facility medical record included a copy of the discharging hospital's Medication Administration Report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 12 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 (MAR), dated, October 12, 2020. This MAR documented the time of each medication Resident A received prior to discharge from the hospital to the facility on October 12, 2020. The MAR indicated the following: - "insulin glargine (Lantus) (medication to control high blood sugar) inject 17 units Dose: 17 units Freq: (frequency) 2 times daily Route: SubQ (subcutaneously-under the skin)." The MAR indicated the resident received a dose at 9:31 a.m. and was to receive the next dose at 9:00 p.m., on October 12, 2020. - "insulin lispro (HumaLOG, ADMELOG) Inject 8 Units Dose: 8 units Freq: 3 times daily before meals Route: SubQ (subcutaneous - under the skin) Admin (administration) Instructions: Give within 15 min (minutes) prior to meal..." Further review of Lexicomp indicated, "Insulin lispro (Humalog) is a rapid-acting insulin analog...Insulin requirements vary dramatically between patients and dictate frequent monitoring and close medical supervision. Diabetes mellitus, type 1, treatment: SubQ: Insulin lispro must be used concomitantly with intermediate or long-acting insulin." The MAR indicated Resident A received a dose at 7:47 a.m., and 11:47 a.m., and was scheduled to receive the last dose at 5:30 p.m., on October 12, 2020. Review of Resident A's facility record included a document titled, "Order Summary Report," which indicated the following order dated October 12, 2020: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 13 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 - "Admit to (initials of facility) 10/12/2020 under the services of (name of doctor) with the following Dx (diagnosis)...Insulin dependent Type 1 DM (diabetes mellitus)..." Further review of Resident A's facility document titled, "Order Summary Report," indicated two orders for the insulin Humalog dated October 12, 2020: - "HumaLOG solution 100 Unit/ML (milliliter) (Insulin Lispro) Inject 8 unit subcutaneously before meals for diabetes mellitus give within 15 minutes prior to meal. Hold if not eating > (greater than) 25% of meals." - "HumaLOG Solution 100 Unit/ML (Insulin Lispro) Inject 8 units subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals." Review of Resident A's facility document titled, "Order Summary Report," indicated an order also dated October 12, 2020, for, "Lantus Solution 100 Unit/ML (insulin glargine) Inject 17 unit subcutaneously two times a day for diabetes mellitus." Review of a document from the discharging hospital titled, "Summary of Care," dated October 12, 2020, for Resident A indicated that the resident had two blood sugar tests prior to discharge from the hospital to the facility. One at 6:15 a.m., on October 12, 2020, with a blood sugar level of 192, and the last test prior to discharge at 11:44 a.m., with a level of 100. No orders were found in Resident A's facility record to monitor blood sugar levels. Review of Resident A's "Admission Summary," dated, October 12, 2020, at 6:40 p.m., indicated, "Admitted to (initials of facility) at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 14 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 2pm 10/12/2020, this 67 yo (sic) (year old) lady from (name of discharging hospital) under the service of (doctor's name)...Resident is alert, able to make needs known, not in respiratory distress...Resident ate 25% for supper...(name of doctor) made aware of this admission..." A review of Resident A's facility document titled, "Admit/Re-Admit Nursing Evaluation," dated, October 12, 2020, indicated, "Verification: 1. Attending Physician Notified, Orders Read Back and Verified? a. Yes 2. If Yes, Indicate Date and Time of Notification, Orders Verification: 10/12/2020." Review of Resident A's facility care plans indicated the following care plan dated, October 12, 2020, "Focus- The resident has Diabetes Mellitus Type 1(insulin dependent)...Goal - The resident will be free from any s/s (signs or symptoms) of hyperglycemia (high blood sugar levels) through the review date...The resident will have no complications related to diabetes through the review date. Interventions...Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness...Educate regarding medications and importance of compliance..." A review of Resident A's facility MAR indicated that the physician ordered insulin Humalog for the 4:45 p.m., October 12, 2020, administration was not given. Further review of the facility MAR for Resident A indicated the physician ordered administration of Lantus Solution scheduled for 9:00 p.m. on October 12, 2020, was not given. The record indicated that Resident A failed to receive any physician ordered insulins on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 15 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 October 12, 2020, after admission to the facility. A review of Resident A's facility "Progress Notes," indicated the following entry dated, October 12, 2020, at 9:38 p.m., "OrdersAdministration Note: Lantus Solution 100 Unit/ml. Inject 17 unit subcutaneously two times a day for diabetes mellitus. New admit, awaiting pharmacy for delivery will endorse." This progress note was authored by a license vocation nurse (LVN 1). Further review of Resident A's facility "Progress Notes," indicated the following entry dated, October 13, 2020, at 6:33 a.m., "Heath Status Note...Resident remains alert, oriented and verbally responsive. Able to make needs known...No adverse drug reactions noted at this time. No n/v (nausea and vomiting)..." A review of Resident A's MAR for October 13, 2020, indicated that the physician ordered administration of the insulin Humalog scheduled for 6:45 a.m., was not given. Further review of Resident A's facility "Progress Notes," indicated the following entry, "OrdersAdministration Note," dated, October 13, 2020, at 10:03 a.m., "HumaLOG Solution 100 Unit/ml. Inject 8 unit subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals (sic) resident vomited all she ate." A review of Resident A's MAR for October 13, 2020, indicated that Resident A did not receive the physician ordered insulin, Humalog, on October 13, 2020. Further review of Resident A's facility medical record found no documentation that indicated the resident's physician was notified that the ordered insulins had not been given on October FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 16 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 12th or 13th, 2020. A review of Resident A's facility "Progress Notes," indicated the following entry, "Health Status Note," dated October 13, 2020, at 11:30 a.m., "At 10:17 this morning resident was noted to be sweating and breathing fast. She was able to respond to her husband who was on the phone at the time. Blood sugar was checked and showed "HI". (A review of the leading provider of blood sugar monitoring systems, "Accu-Chek" indicated, "If the letters HI are displayed on the screen, the blood glucose may be higher than the measuring range of the system. The meter is designed to provide a numerical value for blood glucose in the range of 20-600 mg/dL (milligram/deciliter)." CNA (certified nursing assistant) reported to this writer earlier that resident vomited breakfast food (sic)...(name of doctor) and husband informed...Husband was updated of residents' (sic) condition and at 10:54am (sic) agreed that resident be transferred to hospital preferably to (name of discharged hospital). Call to 911 was placed and they arrived about 11:15. This writer went to check on the resident at about this time and found her to be unresponsive (unconscious, possibly dead or dying)...Resident was transferred out of the facility around 11:25am (sic)." Further review of Resident A's facility medical record found no documentation that any blood sugar check had been done prior to 10:00 a.m., on October 13, 2020, 20 hours after admission to the facility. Per the American Diabetes Association (ADA), Blood glucose (blood sugar) monitoring is the primary tool to find out if blood glucose levels are within a targeted range. "It is important for blood glucose levels to stay in a healthy range." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 17 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 ADA indicated that the recommended blood sugar levels should be between 70 and 130 mg/dL before meals, less than 180 mg/dL after meals. The American Diabetes Association further indicated; "Hyperglycemia is the technical term for high blood sugar. Hyperglycemia occurs when the body has too little insulin or when the body cannot use insulin properly. A few of the causes...Not enough insulin or oral diabetes medications..." The ADA further indicated, "Hyperglycemia (high blood sugar) can be a serious problem if left untreated. It is important to treat as soon as detected. Failure to treat hyperglycemia, can result in ketoacidosis (diabetic coma)..." A review of Resident A's emergency transport's, "Patient Care Report," dated, October 13, 2020, indicated the paramedics were called at 10:56 a.m., and were with the resident by 11:12 a.m. Further review of Resident A's emergency transport's, "Patient Care Report," indicated, "Narrative:...To (name of facility) SNF (skilled nursing facility) for "Difficulty breathing, high blood sugar," To be greeted at entrance by staff. Staff stopped (number of transport) crew for COVID screening procedures. During procedures, staff member appeared stating, "Hurry, she's unresponsive now." (number of transport) proceded (sic) as quickly as possible to room directed by staff. All staff members outside of PT's (patient) room. (Number of transport) found PT laying semi-fowlers (positioned on the back with the head and trunk raised to between 15 and 45 degrees) in bed, unresponsive with agonal breathing (medical term for the gasping or struggling to breathe) PT immediately moved to gurney for transport due to PT condition...staff stated PT had "High FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 18 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 Blood Sugar" and was found with difficulty breathing prior to calling 911...PT arrived yesterday from (name of discharging hospital) for rehabilitation...PT moved to ambulance and loaded. Upon loading PT became pulseless (absence of heart beat)...Chest compressions started..." A review of Resident A's hospital record titled, "ED (emergency department) Aware Note," dated October 13, 2020, indicated, "History or Presenting Illness: The patient is a 67 year(s) old female complaining of cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness). (Name of Resident A) was seen by me at Oct-13-2020 11:33. The patient's chief complaint quote was full arrest (abrupt loss of heart function)..." Resident A's, "ED Aware Note," further indicated, "...Pt arrived pulseless in asystole (state of total cessation of electrical activity from the heart) after prolonged downtime with delayed initiation of CPR (Cardiopulmonary resuscitation- emergency procedure that combines chest compressions with artificial ventilation)..." Further review of Resident A's hospital, "ED Aware Note," dated, October 13, 2020, indicated, "TOD (time of death) called 1140...Dx (diagnosis) asystole, cardiopulmonary arrest, hyperglycemia...blood glucose 477..." A review of Resident A's hospital record titled, "Discharge Diagnosis," indicated, "asystole, cardiac arrest and hyperglycemia." A review of Resident A's "Certificate of Death," dated, November 25, 2020, indicated, "Immediate Cause- final disease or condition resulting in death: (A). Cardiac Arrest..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 19 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 Review of a journal titled, "Cardiovascular Complications of Ketoacidosis," in the national publication, "U.S. Pharmacist," dated, February 17, 2016, indicated, "Ketoacidosis is a serious medical emergency requiring hospitalization...It is most commonly associated with several cardiovascular (relating to the heart) complications (per the Mayo Clinic complications of the heart include sudden cardiac arrest)...Ketoacidosis most commonly occurs in insulin-dependent diabetes with omission (left out or excluded) of insulin..." On December 28, 2020, at 3:09 p.m., a phone interview was conducted with a licensed vocational nurse (LVN 2). LVN 2 confirmed that he had provided care for Resident A on the morning of October 13, 2020. LVN 2 was asked if he had administered the physician ordered insulins during his shift. LVN 2 stated that he could not remember exactly which insulin he had given but stated after the doctor was notified, he believed that he had given the Lantus. LVN 2 continued that his supervisor had contacted the doctor to get an order to check the resident's blood sugar level. LVN 2 stated when he checked the blood glucose monitor it kept reading, "high." LVN 2 was asked if there had been an order to monitor or check Resident A's blood sugar or an order for a sliding scale (a progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges). LVN 2 stated, "I guess not." LVN 2 continued that there was no order to check the resident's blood sugar. LVN 2 stated that his supervisor had called the physician to get the order to have the resident's blood sugar checked on October 13, 2020. On December 29, 2020, at 4:07 p.m., a phone interview was conducted with Resident A's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 20 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 attending physician (AP) at the facility. The AP was asked if she had been notified that Resident A had failed to receive her ordered insulins October 12th and October 13th. The AP stated that she had not been notified that the resident had not received her medications. The AP continued that she does not "always get notified for things like that." The AP was then asked for a resident with diabetes would it be expected to have an order to check the resident's blood sugar and have a sliding scale. The AP stated, "Yes, of course," there should have been an order. On December 30, 2020, at 10:16 a.m., a phone interview was conducted with the facility's Director of Nursing (DON). The DON was asked the facility's expectation to notify the physician if medications were not available to be given at the ordered time. The DON stated that if medications were not delivered or not available to be given, the staff should have called the physician and informed the physician that the medications were late or not available to get new orders. The DON was asked if the facility had an E-kit (emergency medication kit). The DON confirmed that the facility had an Ekit. After checking the facility E-kit the DON stated that the E-kit had Humalog and a regular acting insulin but not the Lantus. The DON was asked the expectation for an order to check the blood sugar levels. The DON stated that even though there was no order, the blood sugar should have been monitored. The DON continued that with a diagnosis of diabetes there must be blood sugar monitoring. The DON stated that the physician should have been called to obtain an order to check the blood sugar levels. On December 30, 2020, at 10:30 a.m., a phone interview was conducted with LVN 1. LVN 1 confirmed that she had provided care for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 21 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 Resident A on October 12, 2020. LVN 1 stated she had worked a double shift that day from 6:30 a.m. to 11:00 p.m. LVN 1 was asked if she had administered Resident A's insulins. LVN 1 stated, "No." LVN 1 further stated that the medications had not been delivered from the pharmacy to the facility during her shift. LVN 1 continued that she had not had the medications at that time to administer. LVN 1 was asked if she had called to inform the physician that the medications were not available to give. LVN 1 stated, "I didn't call personally." LVN 1 stated that she was unaware if anyone had called the physician to notify them that the medications were not available to give at the ordered times. LVN 1 was then asked if it was expected for the physician to be notified if a medication was not available to be given at the ordered time. LVN 1 stated, "Yes," it would be expected to have notified the physician. LVN 1 was asked if she had monitored Resident A's blood sugar levels. LVN 1 stated, "No." LVN 1 continued, "There was not an order for blood sugar checks." Review of a facility policy titled, "Diabetes Mellitus: Monitoring and Management Protocol," undated indicated, "...Type 1 DM (diabetes Mellitus)...Residents with type 1 DM using a multiple-dose insulin regimen may test before meals and at bedtime. Requires injections of insulin to control diabetes and prevent Ketoacidosis..." On December 30, 2020, at 2:04 p.m., a phone interview with conducted with one of the facility's registered nurses (RN 1). RN 1 confirmed that she had been Resident A's admitting nurse on October 12, 2020. RN 1 stated that she had input Resident A's facility orders from the discharge orders received from the discharging hospital. RN 1 was asked that given Resident A's diagnosis of diabetes, should there have been an order to monitor her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 22 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 blood sugar and an order for a sliding scale? RN 1 stated, "I agree." RN 1 continued, "Yes," there should have been an order for blood sugar checks and a sliding scale. RN 1 stated there should have been an order to monitor the blood sugar. RN 1 stated that she had spoken with the nurses at the facility the next day and informed them that if a resident had a diagnosis of diabetes and there was no order for blood sugar monitoring, they must call the physician and get an order to check the blood sugar. A review of the Vocational Nursing Practice Act indicated, "Scope of Vocational Nursing Practice: The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan..." It further indicated, "...Performance Standards: (a) A licensed vocational nurse shall safeguard patients'/clients' health and safety by actions that include but are not limited to the following:...(2) Documenting patient/client care in accordance with standards of the profession..." Review of the Business and Professions Code, Division 2, Chapter 6. Nursing, Article 2. Scope of Regulation, amended 1974, indicated, "...(b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: (1) Direct and indirect patient care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 23 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician..."

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 04/17/2021 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 24 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to provide pharmaceutical services that assured the accurate receiving, dispensing, and administering of drugs to meet the needs of one of seven sampled residents (Resident A). This failure occurred when Resident A failed to receive the ordered medication insulin (medication that lowers the level of glucose [sugar] in the blood) after admission to the facility in time to be administered per the physician's orders. Findings: On December 3, 2020, at 11:20 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment. On December 3, 2020, a review of Resident A's facility medical record was conducted. Resident A was admitted to the facility on October 12, 2020, with diagnoses that included pyelonephritis (inflammation of the kidney due to a bacterial infection), hemiplegia and hemiparesis following a cerebral infarction (paralysis and or weakness of one side of the body following a stroke), essential hypertension (high blood pressure), and insulin dependent type 1 diabetes (disease in which the body does not make enough insulin to control blood sugar levels). Review of Resident A's facility document titled, "Order Summary Report," indicated the following order dated October 12, 2020: - "Admit to (initials of facility) 10/12/2020 under FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 25 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 services of (name of doctor) with the following Dx (diagnosis)...Insulin dependent Type 1 DM (diabetes mellitus)..." Further review of Resident A's facility document titled, "Order Summary Report," indicated two orders for the insulin Humalog dated October 12, 2020: - "HumaLOG solution 100 Unit/ML (milliliter) (Insulin Lispro) Inject 8 unit subcutaneously before meals for diabetes mellitus give within 15 minutes prior to meal. Hold if not eating > (greater than) 25% of meals." - "HumaLOG Solution 100 Unit/ML (Insulin Lispro) Inject 8 units subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals." Review of Resident A's facility document titled, "Order Summary Report," indicated an order also dated October 12, 2020, for, "Lantus Solution 100 Unit/ML (insulin glargine) Inject 17 unit subcutaneously two times a day for diabetes mellitus." Review of Resident A's "Admission Summary," dated, October 12, 2020, at 6:40 p.m., indicated, "Admitted to (initials of facility) at 2pm 10/12/2020, this 67 yo (sic) (year old) lady from (name of discharging hospital) under the service of (doctor's name)...(name of doctor) made aware of this admission..." A review of Resident A's facility document titled, "Admit/Re-Admit Nursing Evaluation," dated, October 12, 2020, indicated, "Verification: 1. Attending Physician Notified, Orders Read Back and Verified? a. Yes 2. If Yes, Indicate Date and Time of Notification, Orders Verification: 10/12/2020." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 26 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 A's facility MAR (Medication Administration Record) indicated that the physician ordered insulin Humalog for the 4:45 p.m., October 12, 2020, administration was not given. Further review of the facility MAR for Resident A indicated the physician ordered administration of Lantus Solution scheduled for 9:00 p.m. on October 12, 2020, was not given. The record indicated that Resident A failed to receive any physician ordered insulins on October 12, 2020, after admission to the facility. A review of Resident A's facility "Progress Notes," indicated the following entry dated, October 12, 2020, at 9:38 p.m., "OrdersAdministration Note: Lantus Solution 100 Unit/ml. Inject 17 unit subcutaneously two times a day for diabetes mellitus. New admit, awaiting pharmacy for delivery will endorse." This progress note was authored by a license vocation nurse (LVN 1). A review of Resident A's MAR for October 13, 2020, indicated that the physician ordered administration of the insulin Humalog scheduled for 6:45 a.m., was not given. Further review of Resident A's facility "Progress Notes," indicated the following entry, "OrdersAdministration Note," dated, October 13, 2020, at 10:03 a.m., "HumaLOG Solution 100 Unit/ml. Inject 8 unit subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals (sic) resident vomited all she ate." A review of Resident A's MAR for October 13, 2020, indicated that no physician ordered administration of the insulin Humalog was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 27 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 administered on October 13, 2020. On December 28, 2020, at 3:09 p.m., a phone interview was conducted with a licensed vocational nurse (LVN 2). LVN 2 confirmed that he had provided care for Resident A on the morning of October 13, 2020. LVN 2 was asked if he had administered the physician ordered insulins during his shift. LVN 2 stated that he could not remember exactly which insulin he had given but stated after the doctor was notified, he believed that he had given the Lantus. LVN 2 continued that his supervisor had contacted the doctor to get an order to check the resident's blood sugar level. LVN 2 stated that when he checked the blood glucose monitor it kept reading, "high." On December 30, 2020, at 10:16 a.m., a phone interview was conducted with the facility's Director of Nursing (DON). The DON was asked the facility's expectation to notify the physician if medications were not available to be given at the ordered time. The DON stated that if medications were not delivered or not available to be given, the staff should have called the physician and informed the physician that the medications were late or not available to get new orders. The DON was asked if the facility had an E-kit (emergency medication kit). The DON confirmed that the facility had an Ekit. After checking the facility E-kit the DON stated that the E-kit had Humalog and a regular acting insulin but not the Lantus. On December 30, 2020, at 10:30 a.m., a phone interview was conducted with LVN 1. LVN 1 confirmed that she had provided care for Resident A on October 12, 2020. LVN 1 stated she had worked a double shift that day from 6:30 a.m. to 11:00 p.m. LVN 1 was asked if she had administered Resident A's insulins. LVN 1 stated, "No." LVN 1 further stated that the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 28 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 medications had not been delivered from the pharmacy to the facility during her shift. LVN 1 continued that she had not had the medications at that time to administer. LVN 1 was asked if she had called to inform the physician that the medications were not available to give. LVN 1 stated, "I didn't call personally." LVN 1 stated that she was unaware if anyone had called the physician to notify them that the medications were not available to give at the ordered times. LVN 1 was then asked if it was expected for the physician to be notified if a medication was not available to be given at the ordered time. LVN 1 stated, "Yes," it would be expected to have notified the physician. Review of a facility policy titled, "Drug Ordering and Receipt," undated, indicated, "...10. If the ordered medication is not available from the pharmacy, the pharmacy will call the nurse on duty with an explanation, as well as alternative medications that can be used instead. The physician is then to be called for an order change to ensure that the resident receives the necessary medication. Under no circumstances should there be missed doses of medications due to the drug(s) "not being available from the pharmacy..."

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 04/17/2021 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure that one of seven sampled residents (Resident A) was free of a significant medication error. This failure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 29 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 occurred when Resident A did not receive the ordered insulin medication (medication that lowers the level of glucose [sugar] in the blood) from the pharmacy after admission to the facility. The omissions of the physician ordered insulin resulted in Resident A's blood sugar to rise throughout the night, which necessitated Resident A to be sent to the acute care hospital via 911 the next morning where she expired (died) shortly after arrival in the hospital's emergency room (ER). Findings: On December 3, 2020, at 11:20 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment. On December 3, 2020, a review of Resident A's facility medical record was conducted. Resident A was admitted to the facility on October 12, 2020, with diagnoses that included pyelonephritis (inflammation of the kidney due to a bacterial infection), hemiplegia and hemiparesis following a cerebral infarction (paralysis and or weakness of one side of the body following a stroke), essential hypertension (high blood pressure), and insulin dependent type 1 diabetes (disease in which the body does not make enough insulin to control blood sugar levels). A review of a record for Resident A from the discharging hospital titled, "Physician Discharge Summary," dated October 12, 2020, indicated, "Discharge Medications: -insulin glargine 100 unit/mL (milliliter) injection Commonly known as LANTUS. Instructions: Inject 0.17 mLs (17 Units total) into the skin 2 (two) times daily. Dose: 17 Units FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 30 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 What changed: * how much to take *how to take this *when to take this *additional instructions." A review of Lexicomp, a nationally recognized drug reference indicated, "Insulin glargine (Lantus) is used to lower blood sugar in patients with high blood sugar (diabetes) and is a long-acting insulin. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision. Insulin glargine must be used concomitantly (in combination) with rapid or short-acting insulins i.e., multiple daily injection regimen." -insulin lispro 100 unit/mL injection Commonly known as: HumaLOG Instructions: Inject 8 units subcutaneously (SubQ - under the skin) TIDAC (Three times a day before meals) if eating > (greater than) 25% of meal. What changed: additional instructions -insulin lispro 100 unit/mL injection Commonly known as: HumaLOG Instructions: Inject 0-5 units three times daily before meals as needed per sliding scale: BG (blood glucose) <70 = hold rapid-acting insulin and see hypoglycemia (low blood sugar) measures. 70-150 = No correction 151-200 = 1 unit, 201-250 = 2 units, 251-300 = 3 units, 301350 = 4 units, > 350 = 5 units and notify provider on call. What changed: You were already taking a medication with the same name, and this prescription was added. Make sure you understand how and when to take each..." Review of Lexicomp indicated, "Insulin lispro (Humalog) is a rapid-acting insulin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 31 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 analog...Insulin requirements vary dramatically between patients and dictate frequent monitoring and close medical supervision. Diabetes mellitus, type 1, treatment: SubQ: Insulin lispro must be used concomitantly with intermediate or long-acting insulin." Further review of Resident A's facility medical record included a copy of the discharging hospital's Medication Administration Report (MAR), dated, October 12, 2020. This MAR documented the time of each medication Resident A received prior to discharge from the hospital to the facility on October 12, 2020. The MAR indicated the following: - "insulin glargine (Lantus) (medication to control high blood sugar) inject 17 units Dose: 17 units Freq: (frequency) 2 times daily Route: SubQ." The MAR indicated the resident received a dose at 9:31 a.m. and was to receive the next dose at 9:00 p.m., on October 12, 2020. - "insulin lispro (HumaLOG, ADMELOG) Inject 8 Units Dose: 8 units Freq: 3 times daily before meals Route: SubQ Admin (administration) Instructions: Give within 15 min (minutes) prior to meal..." The MAR indicated Resident A received a dose at 7:47 a.m., and 11:47 a.m., and was scheduled to receive the last dose at 5:30 p.m., on October 12, 2020. Review of Resident A's facility record included a document titled, "Order Summary Report," which indicated the following order dated October 12, 2020: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 32 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 - "Admit to (initials of facility) 10/12/2020 under the services of (name of doctor) with the following Dx (diagnosis)...Insulin dependent Type 1 DM (diabetes mellitus)..." Further review of Resident A's facility document titled, "Order Summary Report," indicated two orders for the insulin Humalog dated October 12, 2020: - "HumaLOG solution 100 Unit/ML (milliliter) (Insulin Lispro) Inject 8 unit subcutaneously before meals for diabetes mellitus give within 15 minutes prior to meal. Hold if not eating > (greater than) 25% of meals." - "HumaLOG Solution 100 Unit/ML (Insulin Lispro) Inject 8 units subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals." Review of Resident A's facility document titled, "Order Summary Report," indicated an order also dated October 12, 2020, for, "Lantus Solution 100 Unit/ML (insulin glargine) Inject 17 unit subcutaneously two times a day for diabetes mellitus." Review of a document from the discharging hospital titled, "Summary of Care," dated October 12, 2020, for Resident A indicated that the resident had two blood sugar tests prior to discharge from the hospital to the facility. One at 6:15 a.m., on October 12, 2020, with a blood sugar level of 192, and the last test prior to discharge at 11:44 a.m., with a level of 100. No orders were found in Resident A's facility record to monitor blood sugar levels. Review of Resident A's "Admission Summary," dated, October 12, 2020, at 6:40 p.m., indicated, "Admitted to (initials of facility) at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 33 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 2pm 10/12/2020, this 67 yo (sic) (year old) lady from (name of discharging hospital) under the service of (doctor's name)...Resident is alert, able to make needs known, not in respiratory distress...Resident ate 25% for supper...(name of doctor) made aware of this admission..." A review of Resident A's facility document titled, "Admit/Re-Admit Nursing Evaluation," dated, October 12, 2020, indicated, "Verification: 1. Attending Physician Notified, Orders Read Back and Verified? a. Yes 2. If Yes, Indicate Date and Time of Notification, Orders Verification: 10/12/2020." A review of Resident A's facility MAR indicated that the physician ordered insulin Humalog for the 4:45 p.m., October 12, 2020, administration was not given. Further review of the facility MAR for Resident A indicated the physician ordered administration of Lantus Solution scheduled for 9:00 p.m. on October 12, 2020, was not given. The record indicated that Resident A failed to receive any physician ordered insulins on October 12, 2020, after admission to the facility. A review of Resident A's facility "Progress Notes," indicated the following entry dated, October 12, 2020, at 9:38 p.m., "OrdersAdministration Note: Lantus Solution 100 Unit/ml. Inject 17 unit subcutaneously two times a day for diabetes mellitus. New admit, awaiting pharmacy for delivery will endorse." This progress note was authored by a license vocation nurse (LVN 1). A review of Resident A's MAR for October 13, 2020, indicated that the physician ordered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 34 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 of the insulin Humalog scheduled for 6:45 a.m., was not given. Further review of Resident A's facility "Progress Notes," indicated the following entry, "OrdersAdministration Note," dated, October 13, 2020, at 10:03 a.m., "HumaLOG Solution 100 Unit/ml. Inject 8 unit subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals (sic) resident vomited all she ate." A review of Resident A's MAR for October 13, 2020, indicated that no physician ordered administration of the insulin Humalog was administered on October 13, 2020. On December 30, 2020, at 10:16 a.m., a phone interview was conducted with the facility's Director of Nursing (DON). The DON was asked the facility's expectation to notify the physician if medications were not available to be given at the ordered time. The DON stated that if medications were not delivered or not available to be given, the staff should have called the physician and informed the physician that the medications were late or not available to get new orders. The DON was asked if the facility had an E-kit (emergency medication kit). The DON confirmed that the facility had an Ekit. After checking the facility E-kit the DON stated that the E-kit had Humalog and a regular acting insulin but not the Lantus. On December 30, 2020, at 10:30 a.m., a phone interview was conducted with LVN 1. LVN 1 confirmed that she had provided care for Resident A on October 12, 2020. LVN 1 stated she had worked a double shift that day from 6:30 a.m. to 11:00 p.m. LVN 1 was asked if she had administered Resident A's insulins. LVN 1 stated, "No." LVN 1 further stated that the medications had not been delivered from the pharmacy to the facility during her shift. LVN 1 continued that she had not had the medications FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 35 of 36 PRINTED: 05/13/2026 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: _______________ 555492 (X3) DATE SURVEY COMPLETED 03/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAK GLEN POST ACUTE 9246 Avenida Miravilla Cherry Valley, CA 92223 (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 at that time to administer. LVN 1 was asked if she had called to inform the physician that the medications were not available to give. LVN 1 stated, "I didn't call personally." LVN 1 stated that she was unaware if anyone had called the physician to notify them that the medications were not available to give at the ordered times. LVN 1 was then asked if it was expected for the physician to be notified if a medication was not available to be given at the ordered time. Review of a facility policy titled, "Drug Ordering and Receipt," undated, indicated, "...10. If the ordered medication is not available from the pharmacy, the pharmacy will call the nurse on duty with an explanation, as well as alternative medications that can be used instead. The physician is then to be called for an order change to ensure that the resident receives the necessary medication. Under no circumstances should there be missed doses of medications due to the drug(s) "not being available from the pharmacy..." Review of a facility policy titled, "Diabetes Mellitus: Monitoring and Management Protocol," undated indicated, "...Type 1 DM (diabetes Mellitus)...Residents with type 1 DM using a multiple-dose insulin regimen may test before meals and at bedtime. Requires injections of insulin to control diabetes and prevent Ketoacidosis..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8WX011 Facility ID: CA240000148 If continuation sheet 36 of 36