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 (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 4 Event ID: 555713 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 555713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowood A Health and Rehabilitation Center 3110 Wagner Heights Road Stockton, CA 95209 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)