Health inspection·October 16, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess resident medication and report to physician when one of three sample resident (Resident 1) did not receive medication for Type 2 Diabetes Mellitus (Type 2 DM - a chronic disease that causes high levels of blood sugar) from August 11, 2024, until September 12, 2024. Residents Affected - Few This failure had the potential to jeopardize the health and well-being of Resident 1 who is medically compromised. Findings: During review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that include Type 2 DM. During an interview on October 15, 2024, at 2:31 PM, with the License Vocational Nurse (LVN 1), the LVN 1 stated resident 1 did not receive Metformin (a medication that treats type 2 DM) from August 11, 2024, until the day it was ordered, September 12, 2024. She further explains that the resident's family informed her that the resident needed to take metformin for diabetes mellitus type 2, but the MAR (Medication administration Record) only calls for a blood sugar check to be performed prior to meals; there is no indication that the blood sugar check is for Type 2 DM; instead, she assumed it was for an infection the resident had. During an interview on October 15, 2024, at 2:51 PM, with the registered nurse (RN 1), the RN 1 identified herself as resident 1's admittance nurse. She claimed that she would not have been aware that the resident was taking Metformin for type 2 diabetes if the family had not informed her. She added that the patient's diagnosis in the admission record included Type 2 DM, but she did not ask the doctor if the resident was taking medication for the condition. During a review of Blood Sugar Summary the record indicated on August 24, 2024, at 8:40 PM, resident ' s blood sugar level was 462 mg/dL (a blood sugar level of 462 mg/dL is considered dangerously high and requires immediate medical attention). During a review of Order Summary Report the record indicated, Metformin HCI oral table 1000 mg given 1000 mg by mouth one time a day for DM was ordered on September 12, 2024. During a review of facility policy and procedure (P&P) titled admission of a Resident dated Page 1 of 2 555162 555162 10/16/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0641 Level of Harm - Minimal harm or potential for actual harm December 19, 2022, indicated, .The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician . Residents Affected - Few 555162 Page 2 of 2