Health inspection·December 12, 2025

CFR § 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 of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: "Highest practicable physical, mental, and psychosocial well-being" is defined as the highest possible level of functioning and well-being, limited by the individual's recognized pathology and normal aging process. Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual. CCR § 72321(a) - Nursing Services Nursing service shall include, but not be limited to, the following: (a) Planning, supervision and evaluation of the nursing care of each patient. On 10/21/2025, the California Department of Public Health (CDPH), received a complaint regarding a resident's quality of care. On 10/27/2025, an unannounced visit was conducted at the facility to investigate the complaint. The facility failed to: 1. Ensure the licensed nurses monitored Resident 1 for signs and symptoms of hyperglycemia and hypoglycemia and monitored the resident blood sugar (BS) level by finger stick. 2. Implement Resident 1's Plan of Care titled, "Diabetes Mellitus, Uncontrolled High Blood Sugar Results" initiated on 9/27/2025 which indicated to monitor Resident 1's BS through finger sticks, and signs and symptoms of hyperglycemia. 3. Ensure the licensed nurses notified Resident 1's physician about the absence of orders for Insulin administration per sliding scale upon the resident re-admission on 10/13/2025. 4. Follow its policy and procedure (P&P) titled, "Diabetic Management and Insulin Administration," which indicated the facility would ensure safe, timely, and effective monitoring of blood sugar (BS) and administration of insulin in accordance with physician's orders and regulatory standards for Resident 1, who had a diagnosis of diabetes mellitus type 2 (DM). As a result of these deficient practices, on 10/21/2025 Resident 1 was admitted to a general acute care hospital (GACH), diagnosed with hyperglycemia and diabetic ketoacidosis ([DKA], a life-threatening complication of diabetes that occurs when the body does not have enough insulin and is left untreated for a prolonged length of time), placing Resident 1 at high risk of falling into a diabetic coma (a condition when the body is overwhelmed with the amount of BS levels, and the resident cannot wake up or respond purposefully to the environment) and possible death. A review of Resident 1's Admission Record indicated Resident 1 a 71-year-old male, was admitted to the facility on 9/27/2025 and readmitted on 10/13/2025. Resident 1's diagnoses included DM with DKA without coma, chronic kidney disease, and quadriplegia. A review of Resident 1's Care Plan titled, "Diabetes Mellitus, Uncontrolled High Blood Sugar Results." indicated to monitor Resident 1 for signs and symptoms of hyperglycemia, monitor BS through finger sticks, and notify the primary care physician PCP) of signs and symptoms of uncontrolled BS. A review of Resident 1's Physician's Order Summary Report dated 9/27/2025 indicated insulin Regular Human Injection Solution (a short-acting insulin solution [starts to work after about 30 to 60 minutes and usually lasts up to 8 hours] used to manage high BS levels in individuals with diabetes) 100 units/milliliter (mL) inject per sliding scale (insulin amount administered based on the level of the BS and the PCP's order for that level of BS [Every six hours for BS 70 mg/dl-140 mg/dl inject 0 units, BS 141mg/dl-175 mg/dl inject 2 units, BS 176 mg/dl-220mg/dl inject 4 units, BS 221mg/dl-300mg/dl inject 6 units, BS 301mg/dl-350mg/dl inject 8 units, BS 351 mg/dl-400 mg/dl inject 10 units, call PCP if BS is less than 70mg/dl or greater than 350mg/dl]) A review of Resident 1's History and Physical (H&P) dated 9/28/2025, indicated Resident 1 could make his needs known but could not make medical decisions. A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 10/7/2025, indicated Resident 1 was rarely/never understood. The MDS indicated Resident 1 was dependent on facility staff for activities of daily living (ADL) including, hygiene, bathing and getting dressed, and mobility functions such as transfers, rolling and sitting up in bed. A review of Resident 1's Physician's Order Summary Report, dated 10/13/2025, indicated an order for Lantus, (a long-acting insulin) to inject 10 units subcutaneously (SQ) at bedtime for DM. The Physician's Order Summary Report did not include any other orders such as orders for insulin (short acting) and BS monitoring for Resident 1 to monitor or treat Resident 1's diagnosis of DM. A review of Resident 1's Medication Administration Record (MAR) dated 10/1/2025 through 10/31/2025, indicated facility staff administered Lantus 10 units SQ daily to Resident 1 from 10/1/2025 to 10/7/2025 (7 doses) and again daily from 10/14/2025 until 10/20/2025 (7 doses). A review of Resident 1's Change in Condition (CIC), dated 10/21/2025 and timed at 12:50 a.m., indicated Resident 1 had "High" BS that could not register on the glucometer. Resident 1 had an altered level of consciousness ([ALOC], not able to respond normally), tachypnea (abnormal rapid, shallow breathing) and oxygen desaturation (an unhealthy decrease in the blood's oxygen levels [reference range 95% - 100%]). Resident 1's blood pressure was 87/46 mmHg (Blood pressure reference range is 90 -120mmHg/60-80 mmHg). The facility staff notified Resident 1's PCP who ordered Resident 1 to be transferred to the GACH via emergency transportation services. A review of the facility's glucometer's user instruction manual, revised 10/2024, indicated if a resident's BS level was above 600 mg/dl, the reading will appear as "High" on the screen. The user manual indicated that the test should be repeated, and if it indicated "High" again, the healthcare professional should be contacted immediately. A review of Resident 1's Physician's Order Summary Report, dated 10/21/2025, indicated transfer Resident 1 to Emergency Department (ED) via emergency transportation services due to high BS, ALOC, tachypnea, and shaking. A review of Resident 1's GACH's ED Note, dated 10/21/2025 and timed at 1:33 a.m., indicated Resident 1 was sent to the GACH due to ALOC, hypotension and hyperglycemia. The ED Note indicated on 10/21/2025 at 2:01 a.m., Resident 1's blood glucose level was 1824 mg/dl. The ED Note indicated Resident 1 was admitted with a diagnosis of DKA with coma and was intubated. The ED Note indicated Resident 1 was started on an insulin drip (a medical treatment used in hospital critical care settings to rapidly and precisely manage severe high BS). A review of an online article from the American Diabetic Association website titled, "Diabetes and DKA (Ketoacidosis), dated 11/12/2025, indicated DKA was a life-threatening condition that could lead to diabetic coma and death. The article indicated treatment for DKA takes place at the GACH but could be prevented by learning the warning signs and checking BS regularly. (https://diabetes.org). During an interview and concurrent record review on 10/28/2025 at 3:26 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Physician's Order Summary Report dated 10/13/2025, the MAR dated 10/1/2025 to 10/31/2025, and the CIC dated 10/21/2025 were reviewed. Resident 1 was admitted to the facility with a diagnosis of DM and should have had his BS monitored daily. There should have been orders for BS monitoring and insulin administration as needed upon the resident's re-admission on 10/13/2025. There was no order to check Resident 1's BS but there should have been an order to check the BS and give insulin coverage as needed if the BS was high. RNS 1 stated if BS checks were not done, and the BS level was not controlled, Resident 1 could go into hyperglycemic shock (a serious medical emergency that happens when a person's blood sugar gets extremely high, causing symptoms such as confusion, and possible unconsciousness). During a telephone interview on 10/29/2025 at 10:37 a.m., with Resident 1's PCP, the PCP stated he was aware Resident 1 was a diabetic with a history of DKA. He (PCP) was not aware Resident 1 did not have orders for BS monitoring. He (PCP) was not aware Resident 1's BS was not checked from 10/13/2025 until 10/21/2025 when Resident 1 had to be transferred out to GACH due to hyperglycemia. During an interview on 10/29/2025 at 3:07 p.m., with the Director of Nursing (DON), the DON stated it was her responsibility to review all newly admitted residents' including Resident 1's clinical documents, to ensure residents received the appropriate care and treatments. The facility staff should have checked Resident 1's BS at least four times a day with orders to administer insulin as needed, when he was readmitted on 10/13/2025. The DON stated she should have clarified the orders with Resident 1's PCP to ensure Resident 1's DM was properly monitored for complications of hyperglycemia. Since BS check was not done routinely there were no means to know when Resident 1's BS level was out of range and as a result Resident 1 experienced ALOC, and was at risk for DKA, unconsciousness, and non-responsiveness. It was the facility's responsibility to make sure residents with a diagnosis of DM had BS checks done regularly with the insulin coverage in place. During an interview and concurrent record review on 10/30/2025 at 2:57 p.m., with RNS 2, Resident 1's care plan, titled "Diabetes Mellitus Uncontrolled High BS Results" dated 9/27/2025, was reviewed. RNS 2 stated Resident 1 had a diagnosis of DM, and the care plan interventions included to monitor Resident 1 for signs and symptoms of hyperglycemia, and to monitor the resident's BS. The facility did not implement Resident 1's care plan for DM. RNS 2 stated the staff did not check the resident's BS four times a day (before meals and at bedtime) and did not administer insulin to Resident 1 as needed per the sliding scale as care planned. Any resident admitted with a diagnosis of DM should have orders for BS monitoring. RNS 2 stated a care plan was a plan on how to take care of residents. The care plan should be initiated and implemented according to each resident's diagnoses. RNS 2 stated a care plan outlined how staff should care for the residents, and if the care plan was not followed, it may lead to a negative outcome (hyperglycemia, DKA, coma) in the residents' condition. A review of the facility's undated policy and procedures (P&P) titled "Diabetic Management and Insulin Administration," indicated to ensure safe, timely, and effective monitoring of blood glucose and administration of insulin in accordance with the physician orders and regulatory standards. A review of the facility's undated P&P titled, "Comprehensive Plan of Care", indicated the facility will develop a comprehensive plan of care for each resident including goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs as identified during each resident's comprehensive assessment. The P&P indicated the care plan must describe services provided to the resident including interventions to attempt to manage risk factors; periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occurred,....re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment, quarterly, and with significant change in status assessment. A review of the facility's undated Job Description titled, "RN Supervisor", indicated the RN supervisor will provide direct nursing care to the residents, and supervise the day-to-day nursing activities performed by the Licensed Vocational Nurse (LVN) and certified nursing assistants (CNA). The job description indicated nursing care functions included consulting with the resident's physician in providing the resident's care, treatment, rehabilitation, as necessary, review the resident's chart for specific treatments, medication orders, diets, as necessary, implement and maintain established nursing objectives and standards, make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status, ensure that direct nursing care be provided by a licensed nurse and/or a certified nursing assistant, ensure that personnel providing direct care to residents are providing such care in accordance with the residents' care plan and wishes, review care plans daily to ensure that appropriate care is being rendered, inform the nurse supervisor of any changes that need to be made on the care plan, ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment, review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs, ensure that your assigned LVNs and CNAs are aware of the resident care plans. A review of the facility's undated job description titled, "Director of Nursing Service/Vice President of Nursing Service", indicated the purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department.....assess resident needs and interview, set resident care standards in accordance with accepted current standards of care to provide high quality care to residents, develop and implement policies and procedures for nursing care of residents, supervise and manage all aspects of the nursing department, assess, direct and supervise residents' care needs....direct, evaluate and supervise all resident care and initiate corrective action as necessary....assess resident care needs and assist in the development of individualized plans of resident care... assess resident pre-admission and/or admission information and determine appropriate level of care....assess resident responses to medication and treatments and make appropriate recommendations for nursing action to be implemented...consistently make accurate level of care determinations, based on the physician's recommendations and the resident's plan of care. The facility failed to: 1. Ensure the licensed nurses monitored Resident 1 for signs and symptoms of hyperglycemia and hypoglycemia and monitored the resident BS level by finger stick. 2. Implement Resident 1's Plan of Care titled, "Diabetes Mellitus, Uncontrolled High Blood Sugar Results" initiated on 9/27/2025 which indicated to monitor Resident 1's BS through finger sticks, and signs and symptoms of hyperglycemia. 3. Ensure the licensed nurses contacted Resident 1's physician to notify about the absence of orders for Insulin administration per sliding scale upon the resident re-admission on 10/13/2025. 4. Follow its P&P titled, "Diabetic Management and Insulin Administration," which indicated the facility would ensure safe, timely, and effective monitoring of BS and administration of insulin in accordance with physician's orders and regulatory standards for Resident 1, who had a diagnosis of DM. As a result of these deficient practices, on 10/21/2025 Resident 1 was admitted to a GACH, diagnosed with hyperglycemia and DKA, placing Resident 1 at high risk of falling into a diabetic coma and possible death. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.