Health inspection·October 9, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility staff failed to notify the physician for one of three sampled residents (Resident 2) when: 1. Resident 2 had twenty-four episodes of high blood pressure (blood pressure higher than 160) and were not reported to the doctor. This failure had the potential to cause Resident 2 to suffer complications. 2. Resident 2 had eight episodes of high blood sugars and were not reported to the doctor. This failure had the potential to cause Resident 2 to suffer complications. Finding: During a review of Resident 2's admission Record (contains demographic and medical information) dated, August 21, 2023, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus (high blood sugar) and Hypertensive Heart Disease (A condition of the heart caused by high blood pressure). During a review of Resident 2's Medication Administration Record (MAR) dated August 1, 2023, through August 30, 2023, it indicated, Hydralazine HCL (medication used to treat high blood pressure) Oral Tablet 100 mg: give 1 tablet by mouth three times a day for hypertension hold for SBP< 100 [systolic blood pressure of Blood Pressure less than 100] Order date June 10, 2023. Further review of Resident 2's MAR dated August 1, 2023, through August 30, 2023, it indicated, Isosorbide Dinitrate (medication used to treat high blood pressure) Oral Tablet 20 mg: give 1 tablet by mouth three times a day for hypertension hold for SBP [Systolic Blood Pressure less than 100] Started Date May 5, 2023. During a review of Resident 2's MAR on August 30, 2023, at 1:30 PM, there was no documented evidence the physician had been notified for the following blood pressure levels: August 9, 2023, at 1:00 PM BP [blood pressure] 190/100, August 9, 2023, at 5:00 PM BP 167/93 August 10, 2023, at 9:00 AM, BP 201/93, August 14, 2023, at 9:00 AM, BP 188/104, August 14, 2023, at 1:00 PM, BP 177/75, August 14, 2023, at 5:00 PM BP 162/89, August 15, 2023, at 9:00 PM, BP 191/97, August 15, 2023, at 1 PM, BP 181/79, August 18, 2023, at 9:00 AM, BP 163/75, August 18, 2023, at 1:00 PM, Page 1 of 3 555494 555494 10/09/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few BP 188/93, August 19, 2023, at 9:00 AM, BP 198/94, August 19, 2023, at 1:00 PM, BP 168/67, August 19, 2023, at 5:00 PM, BP 198/94 August 20, 2023, at 9:00 AM, BP 178/91, August 20, 2023, at 1:00 PM, BP 166/87, August 20, 2023, at 5:00 PM, BP 190/90, August 23, 2023, at 9:00 PM, BP 167/88, August 23,2023, at 5:00 PM, BP 163/90, August 24, 2023, at 9:00 AM, BP 168/90, August 24, 2023, at 1:00 PM, BP 168/68, August 28, 2023, at 9:00 AM, BP 186/97, August 28, 2023, at 1:00 PM, BP 198/88, August 29, 2023, at 9:00 AM, BP 191/98 and August 29, 2023, at 1:00 PM, BP 165/95. During an interview on August 30, 2023, at 2:29 PM, with Clinical Resource Nurse, (CRN), the CRN stated her expectation from the nurses is if they notice a resident with an elevated blood pressure is to recheck BP in both arms to ensure accuracy, to notify the doctor and document in the change of condition which includes nurses progress notes. During a review of Resident 2's Nursing Notes dated from August 1, 2023, through August 30, 2023, there was no documented evidence Resident 2's physician was notified of elevated blood pressure. 2. During a review of Resident 2's MAR dated, August 1, 2023, through August 30, 2023, indicated, insulin NPH (A medication used to treat high blood sugar): Inject 8 units subcutaneously (under the skin) two times a day for Diabetes. Start Date May 19, 2023. During a review of Resident 2's MAR on August 30, 2023, at 1:30 PM, there was no documented evidence Resident 2's physician had been notified for the following blood sugars levels: 6:30 AM: August 1, 2023, blood sugar level 442 mg/dl , August 2, 2023, blood sugar level 400 mg/dl, August 6, 2023, blood sugar level 400 mg/dl, August 10, 2023, blood sugar level 450 mg/dl, and August 20, 2023, blood sugar 65 mg/dl 7:00 PM: August 20, 2023, blood sugar level 581 mg/dl, and August 29, 2023, blood sugar level 400 mg/dl During a review of Resident 2's MAR dated, August 1, 2023, through August 30, 2023, indicated, insulin Lispro (a medication used to treat high blood sugar) Injection Solution Unit/ML: inject 6 unit subcutaneously in the evening for Diabetes Mellitus: Give before meals. Started date: July 04, 2023. During a review of Resident 2's MAR on August 30, 2023, at 1:30 PM, there was no documented evidence Resident 2's physician had been notified for the following high blood sugars levels. 5:00 PM: August 5, 2023, blood sugar level 400mg/dl and August 20, 2023, blood sugar level 416 mg/dl During a review of Resident 2's, Care Plan dated, May 7, 2023, indicated, .focus potential for fluctuating glucose levels secondary to DM [Diabetes Mellitus] Date initiated May 7, 2023. Goal will no sign and symptoms of Glycemic reactions x 90 days. Blood sugar will be within normal limits with no symptoms of hypo/Hyperglycemia for 90 days, date initiated: May 7, 2023, target date: October 29, 2023, Interventions .Monitor for sign & symptoms of glycemic reactions qshift. [every shift] Monitor thirst, excessive appetite or voiding, change in level of consciousness .report to MD promptly. During a review of Resident 2's Nursing Notes dated from August 1, 2023, through August 30, 2023, there was no documented evidence Resident 2's physician was notified of elevated blood sugar or low blood sugar. 555494 Page 2 of 3 555494 10/09/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on August 30, 2023, at 1:38 PM with Registered Nurse 1 (RN 1), RN 1 reviewed the MAR with elevated blood pressure and elevated blood sugars and agree that would be interpreted as physician was not notified. RN 1 further stated, she could not find any Nurses Progress Notes, or any documentation of the physician was notified. RN 1 further stated, The expectation is that MD gets notify, if the MD give an order to administer any additional insulin, then to recheck blood sugar an hour after, to document and to do a change of condition that includes monitoring for seventy-two hours. Same steps for elevated blood pressure. During an interview with License Vocational Nurse 1 (LVN 1), on September 6, 2023, at 5:31 PM, via telephone, LVN 1 stated she remembered on August 20, 2023, Resident 2 had a blood sugar level of 581mg/dl. She stated the reason the doctor was not notified was because she was busy. LVN 1 further stated that when the blood sugar is higher than 400 mg/dl the MD must be notified. During an interview with License Vocational Nurse 2 (LVN 2) on September 6, 2023, at 6:30 PM via telephone, LVN 2 stated, she did not remember if the MD was informed. She further stated if it was not documented on the nurse's progress notes, then the MD was not informed. LVN 2 further stated that when a resident's blood sugar is higher than 400 mg/dl, the MD must be notified, and documented in the nurse's progress notes. LVN 2 further stated, when the blood pressure is elevated, the MD must be notified, and nurses would document in the progress nurse's notes. During a review of the facility's policy and procedure titled, Insulin Administration dated, September 2014, indicated, .Reporting .2. Notify the physician if the resident has signs and symptoms of hypoglycemia that are not resolved if the resident has signs and symptoms of hypoglycemia .) During a review of the facility's policy and procedures titled, Hypertension-Clinical Protocol revised November 2018, indicated, .2. The physician will identify situation where hypertension should be treated and will try to individualize treatment goals and blood pressure targets. a. treatment goals and blood pressure target ranges should be individualized . 555494 Page 3 of 3