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
observations, interviews, and record review, the facility failed to ensure that high blood sugar level readings
above 401 mg/dl (unit of measurement) were reported to the physician in a timely manner as ordered, for
one resident reviewed (Resident 1).
Residents Affected - Few
This failure had potential for delays of treatment for Resident 1 ' s high blood sugar level.
Findings:
On April 23, 2025, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE],
with diagnoses that included diabetes (high blood sugars) and hypertension (high blood pressure).
The Physician's Order dated, March 15, 2025, indicated, to give, .Humalog Injection (Insulin Lispro injectable medication to treat high blood sugar)100 UNIT/ML (unit of measurement) . before meals and at
bedtime as per following blood sugar sliding scale:
- 120-150 (blood sugar reading) mg/dl = 2 units (insulin dose) ;
- 151-200 = 3 units;
- 201-250 = 8 units;
- 251-300 = 10 units;
- 301-350 = 12 units;
- 351-400= 16 units; and
- 401 + = 12 units
The Physician's Order further indicated to call the physician if the blood sugar level was 401 and above.
The electronic Medication Administration Record (eMAR) dated March 1 to 31, 2025, indicated the
following:
- On March 16, 2025, at 6:11AM, the blood sugar level was recorded at 447 mg/dl by Licensed
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555226
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555226
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Springs Healthcare Center at the Carlotta
41505 Carlotta Drive
Palm Desert, CA 92211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Vocational Nurse (LVN) 1 and 12 units of insulin was administered; and
Level of Harm - Minimal harm
or potential for actual harm
- On March 16, 2025, at 11:25 AM, the blood sugar level was recorded at 442 mg/dl by LVN 2 and 12 units
of insulin was administered.
Residents Affected - Few
There was no documented evidence that Resident 1 ' s high blood sugar level of over 400 mg/dL were
communicated to the physician by the LVNs 1 and 2 on March 16, 2025.
On March 23, 2025, at 12:00 p.m., an interview was conducted with LVN 1. LVN 1 stated she was the
licensed nurse who checked Resident 1's blood sugar on March 16, 2025, at 6:11 a.m. LVN 1 stated
Resident 1 ' s blood sugar was 447 mg/dL and she administered 12 units of Insulin Lispro as ordered by
the physician. LVN 1 stated she forgot to call the physician of Resident 1's high blood sugar above 400. LVN
1 stated she should have contacted the physician. LVN 1 further stated Resident 1 may have had more
complications from his diabetes by not notifying the physician.
On March 23, 2025, at 12:15 PM, an interview was conducted with LVN 2 . LVN 2 stated she was the
licensed nurse who checked Resident 1 ' s high blood sugar on March 16, 2025, at 11:25 a.m. LVN 2 stated
Resident 1's blood sugar was 422 mg/dL and she administered 12 units of insulin Lispro as ordered by the
physician. LVN 2 stated she got busy at work and forgot to call about the blood sugar above 400. LVN 2
stated she should have contacted the physician.
On March 23, 2025, at 4:00 p.m., an interview with a concurrent record review was conducted with the
Director of Nursing (DON). The DON stated that licensed nurses were expected to follow the physician
orders on diabetic management. The DON stated the blood sugar checks that were out of range should
have been identified as change of condition and the physician should be contacted. The DON stated the
nurses by not contacting the physician, the resident could have become very sick and hospitalized .
The facility ' s policy and procedure titled, Diabetes-Clinical Protocol, dated September 2017 was reviewed.
The policy indicated, .As part of the initial assessment, the Physician will help identify individuals with
elevated blood .Based on the preceding assessment .the Physician will order appropriate interventions
.The Physician will order desired parameters for monitoring and reporting information related to blood sugar
management. The staff will incorporate such parameters into the Medication Administration Record and
Care Plan. The staff will identify and report issues that may affect a patient's diabetes management .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555226
If continuation sheet
Page 2 of 2
