Health inspection·April 1, 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 observation, interview, and record review the facility failed to ensure physician's orders were followed, for one out of four residents (Resident 4) when Resident 4's blood sugar of 403 mg/dl (milligram/decilitier - unit of measurement) was not reported to the physician according to Resident 4's physician's order. Residents Affected - Few This failure had the potential for Resident 4 to have abnormal blood sugar not controlled or managed and could affect the resident's overlal health condittion. Findings: On March 3, 2025, at 11 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. On March 3, 2025, at 1 p.m., Resident 4 was observed sitting on the edge of the bed. In a concurrent interview with Resident 4, he stated he was unhappy with his care. On March 3, 2025, at 1:05 p.m., Resident 4's record was reviewed. indicated Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar). A review of Resident 4's Medication Administration Record (MAR), for the month of January 2025, included a physician's order, dated January 11, 2025, which indicated, FSBS (finger-stick blood sugar) before meals and at bedtime .Call MD (physician) if less than 60 OR greater than 400 . A review of Resident 4 MAR, for the month of January 2025, indicated on January 22, 2025, at 8 p.m., Resident 4's bedtime blood sugar was 403. There was no documented evidence the physician was notified when Resident 4 had a blood sugar of 403 (above 400) on January 22, 2025, at 8 p.m. On March 3, 2025, at 5:30 p.m., a concurrent interview and review of Resident 4's record was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 4 had a blood sugar level of 403 on January 22, 2025, at 8 p.m. The ADON stated there was no documentation the physician was notified when Resident 4's blood sugar was above 400 on January 22, 2025, at 8 p.m. as indicated in the resident's physician order. The ADON stated the licensed nurse should have notified the physician when Resident 4's blood sugar was 403 on January 22, 2025, at 8 p.m. A review of the facility's policy and procedure titled, Physician Services .Physician's orders, dated January 2023, indicated, .When noting orders, if the licensed staff member is not able to implement the order .then the following procedure is followed to ensure follow-up and timely implementation Page 1 of 2 555742 555742 04/01/2025 Desert Mountain Care Center 47-763 Monroe Avenue Indio, CA 92201

F 0684 Level of Harm - Minimal harm or potential for actual harm of the order .the time frame cannot exceed 48 hours for the physician to respond .The physician does not respond within 48 hours, the physician is contacted by telephone or fax indicating he/she has 24 hours to respond .If the physician does not respond within 24 hours, the licensed staff will notify the Director of Nursing who will involve the Administrator and/or Medical Director to ensure a response from the physician . Residents Affected - Few 555742 Page 2 of 2