Health inspection·March 28, 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 Based on interview and record review, the facility failed to follow physician orders for the administration of insulin for one of two sampled residents (Resident 1). Residents Affected - Few This facility failure had the potential to expose Resident 1 to unsafe insulin doses, and preventable medication errors. Findings: During a concurrent record review and interview, on 3/12/25, beginning at 3:10 p.m., with the Director of Nursing (DON 1) and Health Information Manager (HIM 1), Resident 1's Medication Administration Record (MAR) was reviewed. Resident 1 had an order for Novolog (a fast acting insulin) 100 unit/ml(milliliter) FLEXPEN (a device used to deliver the insulin) inject as per sliding scale .BS (blood sugar) more than 401 give 16 units and call MD. On 1/25/25, Resident 1's blood sugar was 481. Resident 1's Progress Notes indicated a nurse administered only 14 units of insulin and called the MD. The DON 1 and HIM 1 verbalized the nurse administered the incorrect amount of insulin. The DON 1 and HIM 1 could not provide documentation indicating Resident 1's physician acknowledged the nurses notification or responded to it. During a concurrent and interview and record review, on 3/26/25, beginning at 2:40 p.m., with HIM 1, Resident 1's MAR was reviewed. Resident 1's MAR indicated an order for Novolog 100 unit/ml FLEXPEN inject as per sliding scale .BS more than 401 give 5 units and call MD. On 2/24/25, Resident 1's blood sugar was 485. Resident 1's Progress Notes indicated Resident 1 received only 4 units of insulin. The HIM 1 verbalized the nurse should have administered 5 units of insulin but only administered 4 units. The HIM 1 could not provide documentation indicating Resident 1's physician acknowledged the nurses notification or responded to it. During a review of Resident 1's Care Plan dated 12/25/25, indicated in part, Resident 1 Has Diabetes Mellitus with an intervention of to administer Diabetes medication as ordered by the doctor. Page 1 of 4 555163 555163 03/28/2025 Shoreline Care Center 5225 South J Street Oxnard, CA 93033

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 record review and interview, the facility failed to provide quality care for one of two sampled residents (Resident 1) when: Residents Affected - Few 1. Numerous medications were not administered to Resident 1, due to Resident 1 being offsite at a dialysis center. 2. Physical therapy sessions were not provided to Resident 1 as ordered. 3. There was a facility delay following physician orders for Resident 1 to begin weight bearing physical therapy. These facility failures had the potential to result in negative outcomes for Resident 1 and for a delay in care. Findings: 1. During a review of Resident 1's admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including end stage renal disease (a severe condition where the kidneys permanently lose their ability to function properly) type two diabetes (a disease in which blood sugar levels are to high) and dependence on renal dialysis (a life sustaining treatment that filters blood when kidneys fail to remove waste end excess fluid). During a concurrent interview and record review, on 3/12/25, beginning at 12:06 p.m., with the Health Information Manager (HIM 1) Resident 1's Medication Administration Record (MAR) was reviewed. Resident 1's MAR indicated Resident 1 did not receive physician ordered Farxiga (a medication used to treat type two diabetes and chronic kidney disease) on 1/2/25, 1/4/25, 1/7/25, 1/11/25 and 1/14/25, due to Resident 1 receiving dialysis at an offsite dialysis center. Resident 1's MAR further indicated Resident 1 did not receive physician ordered Insulin Glargine (a medication used to treat diabetes) on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25,1/25/25 and 1/30/25, due to Resident 1 receiving dialysis at an offsite dialysis center. The HIM 1 verbalized Resident 1's physician was not made aware of Resident 1 missing these medications due to Resident 1 being at an offsite dialysis center. No documentation could be provided indicating the facility had reached out to Resident 1's physician for either a medication hold or medication administration time change, to ensure Resident 1 received the ordered medications. During a concurrent interview and record review, on 3/26/25, beginning at 2:40 p.m., with the HIM 1, Resident 1's MAR was reviewed. Resident 1's MAR indicated Resident 1 did not receive the following medications and supplements from 1/1/25 through 3/12/25, due to Resident 1 being offsite at a dialysis center: Ferrous Sulfate (used to treat or prevent low iron levels in the blood) give one 325 mg (milligram) tablet one time a day for supplementation at 0900. The facility did not administer this medication to Resident 1 on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 2/18/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25 and 3/11/25. 555163 Page 2 of 4 555163 03/28/2025 Shoreline Care Center 5225 South J Street Oxnard, CA 93033

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Fluticasone Propionate Suspension (a medication used to treat asthma [a lung condition in which your airways narrow]) one spray in each nostril one time a day for asthma at 0900. The facility did not administer this medication to Resident 1 on 1/2/25, 1/4/25, 1/7/25, 1/11/25, 1/13/25 and 1/14/25. Oxybutynin (a medication used to treat symptoms of overactive bladder) give one tablet by mouth one time a day for overactive bladder at 0900. The facility did not administer this medication to Resident 1 on 1/2/25, 1/3/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25 and 3/11/25. Trelegy Ellipta (a medication used to treat lung disorders) one inhalation inhale orally one time a day for wheezing at 0900. The facility did not administer this medication to Resident 1 on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 1/18/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25, 3/11/25. Aspirin (a medication used for a variety of purposes including pain reliver, blood thinner, fever reducer) give one 325 mg tablet by mouth two times a day at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 2/18/25, 2/20/25, 2/22/25, 2/25/25. Docusate Sodium (a medication used to treat constipation) give one 100 mg capsule by mouth two times a day for constipation at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15,25, 2/18/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25 and 3/11/25. Glycolax Powder (a medication used to treat constipation) give 17 grams by mouth two times a day for constipation at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 2/18/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25 and 3/11/25. Macrobid (an antibiotic medication) give one 100 mg capsule by mouth two times a day for a urinary tract infection at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/14/25 and 1/16/25. Gabapentin (a pain medication) give one 100 mg capsule by mouth three times a day for pain at 0900, 1300, and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/2/25, 1/3/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/18/25 and 1/21/25. Insulin Glargine inject 10 units subcutaneously (under the skin) one time a day for diabetes mellitus at 0900. The facility did not administer this medication to Resident 1 on 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 2/18/25, 2/20/25 2/22/25 and 3/1/25. Buspirone HCL (a medication used to treat anxiety disorders) give one tablet orally two times a day for anxiety related to restlessness at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25, 3/11/25. The HIM 1 verbalized Resident 1's physician was not made aware of Resident 1 missing these 555163 Page 3 of 4 555163 03/28/2025 Shoreline Care Center 5225 South J Street Oxnard, CA 93033

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications due to Resident 1 being at an offsite dialysis center. No documentation could be provided indicating the facility had reached out to Resident 1's physician for either a medication hold or medication administration time change, to ensure Resident 1 received the ordered medications. During a review of the facility's policy and procedure titled Hemodialysis Care dated 9/7, indicated in part Newly admitted Dialysis Resident .Coordinate provisions for medication administration. 2. During a concurrent record review and interview, on 3/28/25, starting at 11:05 a.m., with the Rehabilitation Director (RD 1), Resident 1's physical therapy records were reviewed. Resident 1's PT (physical therapy) Evaluation form indicated a treatment plan for Resident 1 to receive PT services five times a week for four weeks from 12/24/24 through 1/20/25. Resident 1's PT Evaluation form indicated Resident 1 only received four of the five scheduled physical therapy sessions during the weeks of 12/25/24 to 12/31/24 and 1/1/25 to 1/7/25. The RD 1 verbalized and confirmed Resident 1 only received four of the ordered five physical therapy sessions during those two weeks. 3. During a concurrent record review and interview, on 3/28/25, beginning at 1:35 p.m., with RD 1, HIM 1 and the Assistant Director of Nursing (ADON 1), Resident 1's medical record was reviewed. Resident 1 received an outside physician order on 1/31/25, of May be WT (weight) bearing to tolerance on both LE (lower extremities). The ADON 1 verbalized this order was not implemented until 2/12/25, due to an order discrepancy. The ADON 1 and RD 1 acknowledged due to this order discrepancy, there was a delay in Resident 1 being evaluated by the physical therapy department for weight bearing physical therapy. During a review of Resident 1's Care Plan dated 12/25/25, indicated in part Resident 1 has an alteration in musculoskeletal status r/t (related to) bilateral ankle fractures .Follow MD orders for weight bearing status. 555163 Page 4 of 4