Other·May 10, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health (DPH) during the investigation of a complaint and a facilityreported incident (FRI). Complaint number: CA00625150 FRI: CA00631430 Representing the DPH: HFEN #19152 The inspection was limited to the specific complaint and FRI investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00625150 and FRI CA00631430.

F684 SS=G Quality of Care CFR(s): 483.25

F684 05/10/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's nursing staff failed to ensure they followed the physician's order, the resident's plan of care, and their policy and procedure to ensure one of three sampled residents (Resident A) received medications, as prescribed by the physician, to treat high blood sugar levels (the concentration of glucose [sugar] in the blood). Resident A, who had a diagnosis of diabetes (a chronic condition associated with abnormally high levels of sugar in the blood) and received insulin (a medication used for the treatment diabetes), based on a sliding scale (the progressive increase in the pre-meal or night time insulin dose based on pre-defined blood glucose ranges) was sent home on a pass with all medications except insulin, supplies to check the resident's blood sugar, the sliding scale with instructions on how to use it and what to do if the resident's blood sugar was outside the sliding scale range. This deficient practice resulted in Resident A's blood sugar becoming elevated at greater than 400 milligrams per deciliter ([mg/dl] normal reference range [NRR] 80-100 mg/dl) after not receiving insulin for almost three days and required a transfer to a general acute care hospital (GACH) with an altered mental status (AMS) and being admitted for three days for treatment. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident A's Admission Records indicated the resident was initially admitted to the facility on 10/2/13 and last readmitted on 9/4/18, with diagnoses including diabetes mellitus without complications with long term (current) use of insulin and dementia (a progressive loss of mental ability). A review of a Minimum Data Set (MDS), an assessment and care screening tool, dated 1/4/19, indicated Resident A scored 6 out of 15 on a Brief Interview for Mental Status ([BIMS] a mental assessment) indicating her cognitive skills for daily decision-making were severely impaired. According to the MDS Resident A received insulin injections for the last seven days. A review of a care plan, dated 10/5/18, and revised on 1/4/19, indicated Resident A was at risk for hypoglycemia (low blood sugar) and/or hyperglycemia (high blood sugar) due to diabetes mellitus. The goal indicated Resident A was not to have any signs and symptoms of hypoglycemia/hyperglycemia or any complications related to diabetes daily. The staff's approaches/interventions included blood sugar checks as ordered and give Humulin Regular Insulin ([short-acting insulin] used to control high blood sugar levels) per sliding scale. A review of a physician's order, dated 9/4/18, indicated the following: 1. Call the physician if the blood sugar (B/S) was greater than 400 mg/dl, give insulin coverage and repeat blood sugar check in 1/2 hour. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Call the physician if the blood sugar was less than 60 mg/dl, give D50 (a glucose solution used for severe low blood sugar) one ampule (a sealed glass or plastic bulb containing solutions for hypodermic [beneath the skin] injection) IVP (intravenous [into the vein] push) and give 1/2 cup orange juice or 1/2 cup of milk if able, give hard candies to eat if able, recheck blood sugar in 30 minutes then call the physician. 3. Check the blood sugar via a finger stick (pricking the tip of a finger to obtain a small sample of blood) with sliding/scale coverage of Humulin Regular Insulin subcutaneously (under the skin) before meals and at bedtime as follows: B/S level of 151-200 mg/dl = 0 units B/S level of 201-250 mg/dl = 2 units B/S level of 251-300 mg/dl = 4 units B/S level of 301-350 mg/dl = 6 units B/S level of 351-400 mg/dl = 8 units A review of a Physician's Order, dated 9/25/18, indicated Resident A may go out on pass with family and with medication. A review of Resident A's Medication Administration Record (MAR), for the month of February 2019, indicated the resident's glucose levels was elevated and she was receiving insulin (Humulin) coverage as follows: 2/1/19 6:30 a.m. - B/S level 396 mg/dl, 8 units of insulin administered. 11:30 a.m. - B/S level 340 mg/dl, 6 units of insulin administered. 4:30 p.m. - B/S 260 mg/dl, 4 units of insulin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administered. 9 p.m. - B/S 300 mg/dl, 4 units of insulin administered. 2/2/19 6:30 a.m. - B/S 276 mg/dl, 4 units of insulin administered. 11:30 a.m. - B/S 400 mg/dl, 8 units of insulin administered. 2/3/19 6:30 a.m. - B/S 320 mg/dl, 6 units of insulin administered. 11:30 a.m. - 400 mg/dl, 8 units of insulin administered. 2/4/19 6:30 a.m. - 333 mg/dl, 6 units of insulin administered. 11:30 a.m. - 390 mg/dl, 8 units of insulin administered. 4:30 p.m. - 216 mg/dl, 2 units of insulin administered. 9 p.m. - 400 mg/dl, 8 units of insulin administered. 2/5/19 11:30 a.m. - 364 mg/dl, 8 units of insulin administered. 9 p.m. - 350 mg/dl, 6 units of insulin administered. 2/6/19 11:30 a.m. - 346 mg/dl, 6 units of insulin administered. 2/7/19 6:30 a.m. - 304 mg/dl, 6 units of insulin administered. 11:30 a.m. - 361 mg/dl, 8 units of insulin administered. 4:30 a.m., 400 mg/dl, 8 units of insulin administered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the MAR, dated 2/8/19, indicated Resident A's blood sugar was 228 mg/dl and she received 2 units of insulin at 6:30 a.m., and at 11:30 a.m., a blank space indicated that there was no blood sugar was obtained. At 4:30 p.m., the same day, it was circled with documentation indicating Resident A went home with family. There was no written documentation indicating insulin or instructions were sent home with the resident and/or her RP (responsible party). A review of a Licensed Personnel Weekly Progress Note, dated 2/8/19 and timed at 10:50 a.m., indicated Resident A was transferred from the facility, at 12:52 p.m., to a clinic for evaluation related to an unrelated event, and later the same day went home with the family on a pass. A review of a Physician's Order, dated 2/8/19 and timed at 3 p.m., indicated to release three days of medication supply for Resident A for out on pass per family/RP request. A review of a Licensed Personnel Weekly Progress Note, dated 2/8/19 and timed at 5:30 p.m., indicated Resident A's family members came to the facility to obtain the residents three day medication supply. Registered Nurse Supervisor 1 (RN 1) asked Licensed Vocational Nurse 1 (LVN 1) to prepare the three days of medication supply. A review of a GACH's Admission Records, indicated Resident A was seen in the emergency department (ED), on 2/10/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11:47 p.m. The GACH's ED note, dated 2/11/19, indicated Resident A presented to the ED for evaluation of AMS and hyperglycemia, per the family, Resident A seemed confused, was agitated and not her normal self. According to the note, the EMS (emergency medical services) checked Resident A's blood sugar and it was high at 499 mg/dl. The family stated Resident A was recently taken out of a nursing home two days prior and had not been receiving her insulin. A review of the GACH's Laboratory results, dated 2/11/19 and timed at 3:15 a.m., indicated Resident A's blood glucose was 353 mg/dl and her urine glucose was elevated at 4+ (indicator of the level of glucose in the urine) (Normal Reference Range [NRR] = negative). A review of the GACH's "History of Present Illness,' dated 2/11/19 and timed at 5:04 p.m., indicated Resident A's history was remarkable for diabetes and resided at a skilled nursing facility (SNF), but left the SNF on 2/8/19 without receiving any insulin until her admission to the GACH (2/10/19). The resident presented to the ED because of confusion and elevated blood sugars (greater than [>] 400). A review of Resident A's Hospital Course, dated 2/13/19, indicated Resident A resided at a SNF, but was taken home by family without a prescription for insulin. The resident became more lethargic (sluggish) and less responsive. The resident's blood sugars were greater than 400 mg/dl and she was brought to the emergency department. The resident's diabetes was controlled with Lantus plus (type of insulin) sliding scale. The resident's family was educated about checking blood sugars FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and will follow-up with a primary care physician. On 3/12/19, at 4:21 p.m., during an interview, LVN 1 stated Resident A had already left the facility when she arrived on her shift (3 p.m. 11 p.m.) that day (2/8/19). LVN 1 stated the family requested a three-day supply of the Resident A's medication and she gave the family the medication for each shift, for three days, separating the medication in plastic envelopes, per dosage and with a label on each envelope. LVN 1 stated there was no insulin in the medication cart and she did not ask the family or anyone at the facility if it had been given to the family already, she just assumed the family had already received it. LVN 1 stated she did not provide the family with the sliding scale instructions and did not ask if they knew how to administer the insulin or if they had equipment to obtain the resident's blood sugar. On 4/1/19, at 4:38 p.m., during a subsequent interview, LVN 1 stated RN 1 brought Resident A's family members to her (2/8/19) and instructed her to give them only Resident A's oral medications. At 5 p.m., on 4/1/19, during an interview, RN 1 stated Resident A's family members came to the facility on 2/8/19, during the evening shift, asking for a three day supply of medication. RN 1 stated the family had previously taken Resident A from the facility and had only taken the resident's oral medications because they had the insulin and equipment at home. RN 1 stated one of the family members was very demanding and she felt intimidated and did not want to risk upsetting her by asking her questions about the Resident A's insulin. RN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated she instructed LVN 1 to only give the family member Resident A's oral medications. On 4/3/19, at 9:40 a.m., during an interview, the Director of Nursing (DON) stated the nursing staff should circle on the MAR and document "out on pass" when the resident was out on pass from the facility. The DON acknowledged "out on pass" documentation only indicated that the resident did not receive medication because she was not in the facility, it does not indicate medication was given to the resident and/or her responsible party (RP). The DON stated the documentation should include that medication, equipment and instruction were sent with the resident and/or the RP and if the medication, supplies, instructions were refused by the resident and/or RP that should be documented as well. The DON stated it was the facility's responsibility to ensure a resident who was under their care have the necessary medication, supplies and instructions for use when they are out of the facility on pass. The DON stated everyone assumed, because the family had previously taken Resident A out of the facility, that the family knew what to do and had equipment and insulin at home. A review of the facility's policy on Dispensing Medication to Residents on Leave/Pass, dated 7/2018, indicated the facility will provide residents with necessary medication(s) when they leave the facility temporarily for a pass with family/responsible party. Residents who are away from the facility during medication passes will be given scheduled medications(s) to take with them. They will only be given the amounts and dosages needed for the length of the anticipated absence. The charge nurse will provide verbal or written directions to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055072 (X3) DATE SURVEY COMPLETED 04/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSECRANS CARE CENTER 1140 W Rosecrans Ave Gardena, CA 90247 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident and/or the person signing out the resident regarding any dispensed medications. The nursing staff will document the resident's absence from the facility on the resident's medicating administration record (MAR), if the resident is absent during one or more medicating passes. If a resident is on leave or pass overnight or for more than three consecutive days, the pharmacy will prepare and dispense his/her medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZYT11 Facility ID: CA910000003 If continuation sheet 10 of 10