Health inspection·May 15, 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 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 Page 1 of 2 555226 555226 05/15/2025 The Springs Healthcare Center at the Carlotta 41505 Carlotta Drive Palm Desert, CA 92211

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 . 555226 Page 2 of 2