Health inspection·July 30, 2025

The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey Complaint # 959426. The inspection was limited to the specific complaint investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. A deficiency was written for Complaint # 959426 at F-Tag 580-G. F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (B)A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 22 CCR 72311 a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). On 5/9/25, an unannounced visit was conducted at the facility to investigate a complaint regarding resident care. Resident 1 is a 65-year-old male who was admitted to the facility on 4/18/25 and has diagnoses of Type 2 Diabetes Mellitus (abnormal level of sugar in the blood), Dysfunction of Bladder, Cerebrovascular Disease (condition of blood vessels/blood flow in the brain), Severe Malnutrition (lacks essential nutrients in the body), Hemiplegia (loss of voluntary movement of one part of the body), Hemiparesis (muscle weakness of one part of the body), Gastrostomy Status (presence of a surgical opening into the stomach, often for nutritional support, a tube is inserted through the abdominal wall into the stomach, allowing for feeding or medication delivery). Based on interview and record review, the facility failed to notify the physician of one of three sampled resident's change of condition when Resident 1's blood sugar/glucose levels were above 200 (normal is 70 - 99 mg [milligrams]/dL [deciliter]) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being sent to the acute hospital and being admitted for dehydration (too little fluid in the body [can occur when the kidneys try to excrete sugar, in response to high blood sugar levels, thru urination leading to dehydration]), hyperglycemia (elevated blood sugar), and hypernatremia (elevated sodium level in the blood [can occur when there is an increase in urination related to high blood sugar and the kidneys lose more water than they retain]). Findings: During a review of the "Physician Orders" (PO), the PO indicated, "Accu-check (device used to check a blood sugar) BID (twice a day) without coverage notify MD (Doctor of Medicine) if BS (blood sugar) less than 60 (mg/dL) or greater than 200 (mg/dL) . . .start date 4/21/25. . ." During a review of Resident 1's "Weights and Vitals Summary" (WVS), the WVS indicated the following results for blood sugar: "4/21/25 7:36 p.m. 387 mg/dL 4/21/25 11:49 p.m. 367 mg/dL 4/22/25 5:14 a.m. 308 mg/dL 4/22/25 7:10 p.m. 396 mg/dL 4/23/25 5:26 a.m. 407 mg/dL 4/23/25 8:58 a.m. 360 mg/dL 4/24/25 7:06 p.m. 372 mg/dL 4/25/25 7:06 p.m. 384 mg/dL." During a review of Resident 1's "S (Situation) B (Background) A (Appearance) R (Review and Notify) Communication Form [SBAR - a communication tool used between healthcare professionals i.e. between the nurse and physician]' dated 4/26/25 at 12:30 a.m., the SBAR indicated, "Resident has deep chest cough, elevated pulse (normal pulse is 60 - 100 beats per minute), temperature 102 (normal temperature is 98.6 degrees Fahrenheit [F - unit of measurement]). . .decision to transfer to acute (hospital) for evaluation." During a review of Resident 1's "ED Note Physician" (EDNP - completed at the acute hospital), dated 4/26/25 at 12:59 a.m., the EDNP indicated, "Biba (brought in by ambulance) from (facility name) for fever and non productice [sic] cough for a few days. . .CMP (comprehensive metabolic panel - blood test) with significant hypernatremia to 151 (normal is 135-145 milliequivalents per liter [mEq/L])), as well as hyperglycemia 532 (mg/dL). . .Given this patient's significant free water deficit (amount of water required to correct dehydration), hyperglycemia concerning for possible HHS (hyperosmolar hyperglycemic state - a serious complication of diabetes characterized by extremely high blood sugar levels. . .severe dehydration that is a life-threatening condition that requires immediate medical attention). . .Sodium level (concentration of sodium level in the blood) 4/26/25 at 1:47 a.m. 151.0 High (normal is 135-145 mEq/L]). . .Glucose level 4/26/25 at 1:47 a.m. 532 (mg/dL) critical. . .UA (urine test) glucose 4/26/25 at 1:48 a.m. > (greater than)=1000 abnormal. . .Final Diagnosis. . .hyperglycemia. . .dehydration. . .hypernatremia. . .Disposition. . .Admit. . ." During a concurrent interview and record review on 5/9/25 at 12:23 p.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON stated on 4/21/25, 4/22/25, 4/23/25, 4/24/25 and 4/25/25 Resident 1 had blood sugar results that were above 200 mg/dL. DON was unable to provide documentation the physician was notified of the elevated blood sugar levels that were greater than 200 mg/dL. DON stated when Resident 1's blood sugar was above 200 mg/dL the physician should have been notified right away. During a concurrent interview and record review on 5/14/25 at 4:26 a.m. with Registered Nurse (RN) 1, Resident 1's clinical record was reviewed. RN 1 stated when Resident 1's blood sugar on 4/22/25 at 5:14 a.m. was 308 mg/dL he did not notify the physician of the blood sugar result, and he should have. RN 1 stated on 4/23/25 when the blood sugar result was 407 mg/dL the physician was notified but he did not document. RN 1 stated he should have documented when the physician was notified. During a concurrent interview and record review on 5/14/25 at 8:12 p.m. with RN 2, Resident 1's "Medication Administration Record" (MAR) dated 4/2025, was reviewed. Resident 1's blood sugar was greater than 200 mg/dL on 4/22/25, 4/23/25, 4/24/25 and 4/25/25. RN 2 stated she did not notify the physician because she was unaware of the physician's order indicating the physician was to be notified for blood sugars greater than 200 mg/dL. RN 2 stated she did not notify the physician, and she should have. During a review of the facility's policy and procedure (P&P) titled "Diabetes - Clinical Protocol)" dated 11/2020, the P&P indicated, "The Physician will order appropriate lab tests. . .and adjust treatments based on these results and other parameters. . .The physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record and care plan." During a review of the facility's policy and procedure (P&P) titled, "Change in a Resident's Condition or Status" dated 2/21, the P&P indicated, "The nurse will notify the resident's attending physician or physician on call when there has been a(an). . .specific instruction to notify the physician of changes in the resident's condition." In violation of the above cited standards, the facility failed to notify the physician of Resident 1's change of condition when Resident 1's blood sugar/glucose levels were above 200. This failure resulted in Resident 1 being sent to the acute hospital and being admitted for dehydration, hyperglycemia, and hypernatremia. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a class "A" citation.