Health inspection·April 16, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents (Resident 1) when: Residents Affected - Few 1. The facility did not follow their own policy for diabetes (blood sugar higher than normal) management; and 2. The facility did not follow the physician's order. These failures had the potential to compromise residents' care and well-being. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] and had diagnoses including type 2 diabetes mellitus (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidney), fracture of second cervical vertebra (a broken bone of second bone in the neck), and traumatic subdural hemorrhage (a condition where blood collects between the skull and the brain's outer covering caused by head trauma). Review of Resident 1's physician's order, dated 2/16/25, indicated Lantus Subcutaneous solution (an insulin to lower blood sugar) 100 unit/ml inject 20 unit subcutaneously at bedtime for DM II, hold for BG (blood glucose) < 100. Review of Resident 1's February 2025 Medication Administration Record (MAR) indicated blood sugar was checked once a day at bedtime for Lantus administration. The MAR indicated Resident 1's blood sugar (BS) at 9 p.m. was: 99 milligrams per deciliter (mg/dL, a unit of measure) on 2/16/25; 89 mg/dL on 2/17/25; 380 mg/dL on 2/18/25; 346 mg/dL on Page 1 of 3 555090 555090 04/16/2025 Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901

F 0684 2/19/25; 395 mg/dL on 2/20/25; 399 Level of Harm - Minimal harm or potential for actual harm mg/dL on 2/21/25. Residents Affected - Few Review of the facility's Diabetes-Clinical Protocol, dated 2001, indicated, for the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin. During an interview and record review with the director of nursing (DON) on 4/16/25, at 10:10 a.m., she confirmed that Resident1's BS was checked once a day at bedtime and stated it was not consistent with the facility's policy titled Diabetes-Clinical Protocol. During an interview and record review with the director of staff development (DSD) on 4/16/25, at 10:20 a.m., she confirmed that there was no documentation indicating the physician was notified of BS increase to 380 mg/dL on 2/18/25 from 89 mg/dL on 2/17/25. The DSD verified that Resident 1's BS monitoring once a day at bedtime was not consistent with the facility's policy titled Diabetes-Clinical Protocol. The DSD acknowledged the resident's BS monitoring should have been consistent with the facility policy. Review of Resident 1's physician's order, dated 2/16/25, indicated monitor for symptoms of COVID-19 (an infectious disease caused by the coronavirus), every shift for possible COVID exposure, If yes to any symptom, temperature greater than 100.0 F (Fahrenheit, a scale of temperature) and/or oxygen saturation (O2 sat, a measurement of how much oxygen is being carried by the red blood cells in the blood) lower than 94 % RA (room air), notify MD (medical doctor) and initiate einteract COC (a form for change of condition). Review of Resident 1's February 2025 MAR indicated Resident 1's O2 sat was: 90% on 2/16/25 on night shift; 91% on 2/17/25 on night shift; 90% on 2/18/25 on day shift and evening shift; 91% on 2/19/25 on night shift; 93 % on 2/20/25 on night shift; and 91% on 2/21/25 on day shift. Review of Resident 1's progress note, there was no evidence the physician was notified when Resident 1's O2 sat was lower than 94 % on above shifts. 555090 Page 2 of 3 555090 04/16/2025 Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's Health status note, dated 2/22/25, indicated Resident 1's O2 sat was 78% RA and BG was 588 mg/dL. The note further indicated Resident 1 was hypoxic (low level of oxygen in the body tissues) and hyperglycemic (high blood) and Residents Affected - Few transferred to hospital. During an interview and record review with the DSD on 4/16/25, at 10:30 a.m., she confirmed that there was no documentation indicating the physician was notified when Resident 1's O2 sat was lower than 94% RA. The DSD acknowledged that the physician should have been notified when Resident1's O2 sat was lower than 94% RA as ordered. During a review of the facility's policy and procedure (P&P) titled Diabetes-Clinical Protocol, dated 2001, the P&P indicated, Monitoring and Follow-Up: 3) for the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin. Adjust monitoring frequency depending on glucose control . During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated 2001, the P&P indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; i. specific instruction to notify the physician of changes in the resident's condition. 555090 Page 3 of 3