Health inspection·March 6, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 follow professional standards of practice for one of the 3 sampled residents (Resident 1) by failing to ensure the physician order to check Resident 1 ' s blood sugar (BS) levels were implemented on 2/28/2025, 3/1/2025 and 3/2/2025. Residents Affected - Few This failure placed Resident 1 at risk for hypoglycemia (low blood sugar) and/or hyperglycemia (high blood sugar) episodes, and potential for complications and hospitalization. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis including diabetes (DM-high blood sugar), hypertension (HTN-high blood pressure) and anxiety disorder (a feeling of fear, dread, and uneasiness). During a review of Resident 1 ' s History and Physical (H&P) dated 2/24/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of residents 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 11/25/2025, the MDS indicated Resident 1 had the capacity of make self-understood and the ability to understand others. The MDS indicated Resident 1 required partial to moderate assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair). During a review of Resident 1 ' s general acute care hospital (GACH) Discharge Medication list dated 2/27/2025 timed 1:39 p.m., the discharge medication list indicated insulin regular 100 unit/ml human recombinant injectable solutions (medicine for DM), inject 4 times a day (before meals and at bedtime) per sliding scale (a diabetes management method where insulin dosage is adjusted based on pre-defined blood glucose ranges). During a review of Resident 1 ' s progress notes dated 2/27/2025 timed 8:27 p.m., the progress notes indicated Resident 1 was readmitted to the facility with diagnosis of DM type 2 with hyperglycemia. The progress notes indicated the medication lists werereviewed with Resident1 and Resident 1 requested to continue all the medications prescribed at the GACH. The progress notes indicated the admission orders were verified with the physician and ordered to continue all medications from GACH. During a review of Resident 1 ' s Medication Administration Record (MAR) for 2/2025, the MAR did not indicate the blood sugar levels were checked as ordered on 2/28/2025, at 6:30 a.m. 11:30 a.m., 4:30 pm and 9:00 p.m. Page 1 of 3 555128 555128 03/06/2025 Downey Community Health Center 8425 Iowa Street Downey, CA 90241

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s MAR for 3/2025, the MAR did not indicate the blood sugar levels were checked on 3/1/2025 and 3/2/2025 as ordered by the physician. During a review of Resident 1 ' s blood sugar (BS) summary, the summary did not indicate Resident 1 ' s BS were monitored from 2/28/2025 until 3/2/2025. The BS indicated Resident 1 ' s BS level at 11:02 p.m. was 491 milligrams/deciliter (mg/dl- a unit of measurement). During a review of Resident 1 ' s physician order for 3/2025, the physician order indicated an order of insulin regular 100 unit/ml, inject subcutaneously before meals and at bedtime (under the skin) per the following sliding scale: 201-250= 2 units; 251-300= 4 units; 301-350= 6 units; 351-400= 8 units and to give 10 units if the blood sugar is more than 400 and call MD (Medical Doctor), was ordered 3/2/2025. On 3/2/2025 at 10:45 p.m., Resident 1 had change of condition (COC). The COC indicated Resident 1 had a BS level of 491 mg/dl. The COC indicated Resident 1 requested to be transferred out to a GACH. During an interview on 3/6/2025 at 10:28 a.m. with Resident 1, Resident 1 stated the facility nurses were aware that he had DM since 2/22/2025 when he was admitted to the facility and were checking his BS. Resident 1 stated 2 days after he returned to the facility from GACH (on 2/28/2025), the facility stopped checking his BS. Resident 1 stated on 3/2/2025, Resident 1 asked a Licensed Vocational Nurse 1 (LVN 1) to check his BS. Resident 1 stated the LVN checked his BS, and the result was 490 mg/dl. Resident 1 stated he felt very scared and anxious and requested to be sent to GACH. During a concurrent interview and record review on 3/6/2025 at 1:30 p.m. with LVN 1, Resident 1 ' s MAR for 2/28/2025, 3/1/2025 and 3/2/2025 were reviewed. LVN 1 stated the x indicated in the MAR administration box on 2/28/2025, 3/1/2025 and 3/2/2025, means Resident 1 ' s BS levels were not monitored/ checked. LVN 1 stated if Resident 1 ' s BS were not checked, the nurses would be unaware of the BS levels, can delay the care and could result in Resident 1 experience hyperglycemic episodes. LVN 1 stated when residents are admitted to the facility, the nurses would check the discharge orders from GACH, call the doctor to verify and write the doctor ' s orders. During an interview on 3/6/2025 at 2:33 p.m. with the Registered Nurse (RN), the RN stated when resident returns to the facility, the hospital sends us a discharge medication orders then the nurses will call the doctor to verify and obtain orders. The RN stated when the insulin was entered in the computer system, the insulin was marked as indefinite, meaning the order will continue even though these residents were transferred to the GACH. The RN stated the facility ' s policy is for nurses to be familiar with residents ' diagnosis. The RN stated it is standards of resident care to follow doctor ' s orders. During an interview on 3/6/2025 at 3:26 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had an order to continue with insulin sliding scale. The DON stated Resident 1 ' s BS were not monitored by nurses on 2/28/2025, 3/1/2025 and 3/2/2025. The DON stated the risk involved when BS are not monitored, was that Resident 1 could have hypoglycemia or hyperglycemia episodes. The DON stated Resident 1 end up having a hyperglycemic episode and was transferred to GACH. During a review of the facility ' s policy and procedures (P&P) titled, Physician Orders, dated 1/2024, the P&P indicated facility licensed nurses should administer medications and treatments in 555128 Page 2 of 3 555128 03/06/2025 Downey Community Health Center 8425 Iowa Street Downey, CA 90241

F 0658 accordance with the MD orders. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s P&P titled, Standard of Care, dated 1/2024, the P&P indicated care should be provided in accordance with physician ' s orders. The P&P indicated, decisions must be made based on clinical evidence, patient preferences, and profession judgment. Residents Affected - Few During a review of the facility ' s P&P titled, Diabetic Management, dated 1/2024, the P&P indicated frequency of blood sugar monitoring will be determined by the MD. The licensed nurses will monitor the blood sugar as ordered and will record results on the clinical record, either on MAR or nursing notes. 555128 Page 3 of 3