Health inspection·April 23, 2024

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 Based on interview and record review, the facility failed to ensure one resident (Resident 1) received treatment and care in accordance with professional standards of practice on 5/16/23 when, Residents Affected - Few 1a. Licensed Nurse (LN) 3 gave orange juice to Resident 1 for a low blood sugar reading of 59 milligrams per deciliter (mg/dL, units of measure. Normal blood sugar is 70 to 99 mg/dL) instead of physician ' s ordered glucagon gel (a sugary gel used to increase a low blood sugar reading) to increase Resident 1 ' s low blood sugar reading, b. LN 3 did not notify Resident 1 ' s physician of the low blood sugar reading per the physician ' s order, and, c. LN 3 did not recheck Resident 1 ' s blood sugar level every 15 minutes until a blood sugar level of at least 110 mg/dL was reached. These failures resulted in Resident 1 ' s physician ' s orders not being followed and had the potential for Resident 1 ' s health to be negatively affected. Findings: Resident 1 was admitted to the facility in mid-2023 with diagnoses which included diabetes (inability for the body to maintain normal blood sugar levels). A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) revealed a brief interview of mental status (BIMS) score of 8 (score can range from 00 for severe impairment to 15 for no impairment) which indicated moderate cognitive impairment (difficulty with thinking clearly). A review of Resident 1 ' s Physicians Order Report dated 5/12/23, indicated, .Glucose Gel .for BS [blood sugar level] <70MG/DL, give glucose gel .or meal tray if available, if BS less than 110MG/DL after dose, administer Q15 mins [every 15 minutes] until BS is stable and Notify MD to re-evaluate diabetic orders . A review of Resident 1 ' s nurse ' s progress note dated 5/16/23 indicated, .0851 [8:51 a.m.] FSBS [blood sugar reading] check with s/sx [signs and symptoms] of diaphoretic skin [sweaty] cold and clammy. Morning FS [blood sugar level] was 59, held insulin [a medication used to control blood sugar levels] and went to kitchen to get res [Resident 1] Orange juice. Rechecked glucose [blood sugar level] 20 min [minutes] after got a reading of 109 .FS was taken reading was 80, lunch served res .approx [approximately] 1400 [2 p.m.] writer went to recheck BS [blood sugar level] after res meal to see any change. FS reading was 81 . Resident 1 ' s blood sugar levels were rechecked twice from 8:51 Page 1 of 4 555713 555713 04/23/2024 Meadowood A Health and Rehabilitation Center 3110 Wagner Heights Road Stockton, CA 95209

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a.m., to 2 p.m., instead of every 15 minutes and did not reach 110 mg/dL as outlined in the physician ' s order. During a concurrent interview and record review with LN 4 on 4/23/24, at 3:33 p.m., Resident 1 ' s nurse ' s progress notes were reviewed. LN 4 confirmed Resident 1 ' s physician ' s order was not followed when LN 3 gave orange juice to Resident 1 instead of glucose gel, did not notify Resident 1 ' s physician of the low blood sugar level, and did not re-check Resident 1 ' s blood sugar levels every 15 minutes. LN 4 stated that LN 3 should have followed Resident 1 ' s physician ' s order but did not. A review of the facility ' s policy and procedure titled, Orders-Physicians revised 2/28/24, indicated, .It is the policy of this facility that drugs and treatments shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs . 555713 Page 2 of 4 555713 04/23/2024 Meadowood A Health and Rehabilitation Center 3110 Wagner Heights Road Stockton, CA 95209

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure medications ordered by the physician were administered to one resident (Resident 1) when dronabinol (a medication used to increase appetite) and vitamin B6 (supplement) were not acquired from the pharmacy in a timely manner. These failures resulted in Resident 1 missing 6 doses of dronabinol and 3 doses of vitamin B6 and had the potential to negatively affect Resident 1 ' s health. Findings: Resident 1 was admitted to the facility in mid-2023 with diagnoses which included severe protein calorie malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients) and gastric bypass (surgery that helps you lose weight by changing how your body handles the food you eat but limits the nutrients that your body can absorb). A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) revealed a brief interview of mental status (BIMS) score of 8 (score can range from 00 for severe impairment to 15 for no impairment) which indicated moderate cognitive impairment (difficulty with thinking clearly). A review of Resident 1 ' s Medication Administration Record (MAR), dated May of 2023, indicated, .vitamin B6 .1 tablet once daily . 05/13/2023 09:00 [9 a.m.] Not Administered: Drug/Item unavailable 05/14/2023 09:00 Not administered: Drug/Item unavailable Comment: pending delivery from pharmacy 05/15/2023 09:00 Not Administered: Drug/Item unavailable . .dronabinol .2 capsules twice a day . 05/13/2023 09:00 Not Administered: Drug/Item unavailable 05/13/2023 17:00 [5 p.m.] Not Administered: Drug/Item unavailable - Comment: waiting for delivery 05/14/2023 09:00 Not Administered: Drug/Item unavailable Comment: pending delivery from pharmacy 05/14/2023 17:00 Not Administered: Drug/Item unavailable 05/15/2023 09:00 Not Administered: Drug/Item unavailable 05/15/2023 17:00 Not Administered: Other Comment: pending delivery from pharmacy. During a concurrent interview and record review with Licensed Nurse (LN) 4 on 4/23/24, at 3:33 p.m., Resident 1 ' s MAR was reviewed. LN 4 confirmed Resident 1 missed 6 doses of dronabinol and 3 doses of vitamin B6 and there was no follow up phone call to the pharmacy, or the physician documented in Resident 1 ' s record. LN 4 stated nursing staff should have contacted Resident 1 ' s physician to get an order to hold the medications until they were delivered from the pharmacy. LN 4 stated 555713 Page 3 of 4 555713 04/23/2024 Meadowood A Health and Rehabilitation Center 3110 Wagner Heights Road Stockton, CA 95209

F 0755 Resident 1 ' s appetite may not have been as good due to the missed doses of medication. Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy and procedure titled, Medication Ordering and Receiving From Pharmacy Provider Ordering and Receiving Non-Controlled Medications dated 2010, indicated, .New medications . please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery . Timely delivery of new orders is required so that medication administration is not delayed . Residents Affected - Some 555713 Page 4 of 4