Health inspection·March 26, 2026

F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).

F684 § 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, On 2/10/2026, at 11:13 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. During the abbreviated survey, CDPH determined that the facility failed to ensure that Resident 1, who was originally admitted on 12/11/2025 and readmitted on 1/11/2026 with a diagnosis including Type 2 Diabetes Mellitus (OM), was provided treatment and services in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) for Resident 1 who had a diagnosis of Type 2 Diabetes Mellitus ([DM] when a hormone called insulin does not work properly or there is not enough of it. This causes the level of glucose [sugar] in the blood to become too high) by failing to:     1. Ensure that its licensed nursing staff reviewed Resident 1’s medical history of Type 2 Diabetes Mellitus (DM) and diabetes management prior to the readmission from the GACH on 1/11/2026. This medical history included Resident 1’s diabetes management, such as checking and monitoring Resident 1’s blood sugar levels by performing fingerstick tests.       2. Verify and document confirmation with Resident 1's attending physician (MD 1) and/or Nurse Practitioner (NP) 1 by transcribing the fingerstick blood glucose monitoring-before meals (AC) and at bedtime (HS)-as ordered in the GACH discharge instructions dated 1/11/2026, upon Resident 1 's readmission to the facility on 1/11/2026.     3. Implement Resident 1 's written care plan dated 12/11/2025 titled “Risk for unstable blood glucose levels ([low blood sugar] and [high blood sugar]),” which requires the facility's licensed nurses to monitor and observe Resident 1 for signs and symptoms of low and high blood sugar levels. The care plan did not address how licensed nurses would measure Resident 1’s blood glucose levels to determine if the resident was experiencing low or high blood sugar levels.      4. Document verification of RN 4 with MD 1 whether fingerstick blood sugar monitoring should be performed when MD 1 ordered for Resident 1 to be on continuous infusion of  Dextrose 5% in Water (D5W) (an intravenous [IV] fluid containing 5 grams of dextrose (sugar) dissolved in 100 mL of water) for poor appetite and hydration from 2/6/2026 to 2/8/2026.     5. Ensure effective communication (LVN 1, RN 1, RN 2, RN 3, RN 4) among the interdisciplinary team regarding Resident 1’s change in condition, critical lab results, and ordered treatments.       As a result of these deficient practices, Resident 1 did not receive required monitoring and timely intervention for hyperglycemia and was administered D5W IV fluids from 2/6/2026 to 2/8/2026 while in a hyperglycemic state. Resident 1 experienced a significant decline in condition, including altered level of consciousness and oxygen saturation of 85 percent (normal range 95–100 percent) on 2/8/2026. Emergency medical services were activated, and paramedics recorded a critically elevated blood glucose level of 530 mg/dL upon arrival. Resident 1 was transferred to the GACH Emergency Department for further evaluation and treatment of altered level of consciousness, hypoxia, and severe hyperglycemia. At the ED, additional blood glucose readings were 530 mg/dL at 4:35 PM and 434 mg/dL at 4:55 PM. The hospital diagnoses included severe sepsis, acute hypoxemic respiratory failure, and uncontrolled diabetes mellitus.         A review of Resident 1’s diabetes care plan titled “Risk for Unstable Blood Glucose Level (low and high blood sugar levels),” initiated during Resident 1’s initial admission at the facility dated 12/11/2025 with a goal date of 3/31/2026, the care plan indicated that Resident 1 should be checked for blood glucose (BG) if the level is below 70 mg/dL, and that if the resident is unconscious or vital signs are absent, staff should administer 1 milligram (mg) of Glucagon (a medication used to increase BG) intramuscularly (IM) and call 911. The care plan did not address how the licensed nurses would measure Resident 1’s blood glucose levels to determine if they were below 70 mg/dL." The care plan interventions further indicated to observe for signs and symptoms (S/S) of high blood glucose levels and report observed S/S to the physician.        A review of Resident 1’s General Acute Care Hospital (GACH) Records titled “Orders Re-Cap (short for recapitulation that means to summarize the main points of something that has already been discussed or happened)” dated 1/11/2026, the Recap indicated to renew (extend validity) Resident 1’s “fingerstick blood sugar before meals (AC-[ante-cebum which means before meals]) and at bedtime (HS –[hour of sleep]).” The GACH records indicated that Resident 1 also had blood sugar checks as needed. The GACH records indicated to notify the physician when the blood sugar was greater than 250 mg/dL, and when the blood sugar was less than 70 mg/dL and to implement hypoglycemia protocol.      A review of Resident 1’s Admission Record (AR), the AR indicated Resident 1 was readmitted to the facility on 1/11/2026, with diagnoses of Type 2 DM and sepsis (a life-threatening medical emergency from an infection).       A review of Resident 1’s Nursing Progress Note dated 1/11/2026 at 6:30 PM, the Notes indicated that Resident 1 was readmitted from the GACH with a diagnosis of sepsis (a life-threatening medical emergency caused by the body’s extreme, dysfunctional response to an infection, leading to tissue damage, organ failure, and potential death).      A review of Resident 1’s Physician Order Report from 1/11/2026 to 1/31/2026, the Report indicated that Resident 1 was to be monitored for signs and symptoms of hypoglycemia such as dizziness, confusion and restlessness three times a day starting on 1/11/2026. The physician’s orders did not include instructions to monitor the resident’s blood sugar levels by performing fingerstick tests AC and HS, nor did they include instructions to monitor for signs and symptoms of hyperglycemia as reflected in the resident’s GACH records. The physician order further indicated Resident 1’s oral diabetes medications including Alogliptin-metformin tablet, 12.5-1,000 mg to be given twice daily for DM – 9 AM and 5 PM, and Jardiance tablet 25 mg, to give one tablet once a day for DM – 9 AM.           A review of Resident 1’s Nursing Progress Note dated 1/11/2026 at 6:35PM, the Note indicated that Registered Nurse (RN) 4 notified Resident 1’s attending physician Medical Doctor (MD 1) regarding Resident 1’s readmission to the facility on 1/11/2026. The Note indicated Resident 1’s Physician Orders were verified and carried out. There is no documented evidence that RN 4 verified with MD 1 whether Resident 1 required continued fingerstick testing to establish baseline blood sugar levels in order to manage the resident’s diabetes.           A review of Resident 1’s History and Physical (H&P) signed and dated on 1/26/2026 signed by NP 1 indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated that Resident 1’s Type 2 DM required monitoring.       A review of a physician order dated 2/5/2026, the order indicated to perform a stat laboratory work for comprehensive metabolic panel (CMP).     A review of Resident 1’s Comprehensive Metabolic Panel (CMP – Blood test) dated 2/5/2026, the Panel indicated that Resident 1 blood sugar was 351 mg/dL.        A review of Resident 1’s Nursing Progress Note dated 2/5/2026 at 10:11 PM, the Note indicated Licensed Vocational Nurse (LVN) 1 communicated the CMP results to MD 1. The documentation further indicated that no new orders were given by MD 1 following this notification.      A review of Resident 1’s physician order dated 2/5/2026, from NP 1, the order indicated to give 0.9 % Normal Saline (NS) via IV 1liter bolus (a single, concentrated dose of medication or fluid given rapidly to achieve a quick effect) one time.     A review of the MAR dated 2/5/2026, the MAR indicated Resident 1 received the 0.9 % NS bolus via IV one time.       A review of Resident 1’s physician order dated 2/6/2026 timed at 7:12 AM, from MD 1, the order indicated to give Dextrose 5% Water (D5W) via IV at 60 cc per hour for a total of 3 liters.       A review of the MAR dated 2/5/2026 to 2/8/2026, the MAR indicated Resident 1 received (D5W) via IV at 60 cc per hour.         A review of a facility cell phone communication with the physician, dated 2/6/2026 at 5:29 AM, showed that a screenshot of Resident 1’s CMP results was texted to MD 1. The text message indicated that MD 1 ordered a change in the resident’s intravenous fluids to dextrose 5% in water (D5W) at a rate of 60 cc/hr, with a total of 3 liters to be administered to Resident 1.          A review of Resident 1’s Nursing Progress Note dated 2/6/2026 at 7:20 AM, the Note indicated MD 1 ordered intravenous (IV-in the vein) hydration for Resident 1 due to poor appetite. The order indicated to infuse D5W via IV at 60 cc/hr times, with a total infusion of 3L’s.           A review of Resident 1’ Nursing Progress Note dated 2/8/2026 at 3:55 PM, the Note indicated that Resident 1 had a change of condition (COC – a significant change in residents health) that Resident 1 was non-verbal, respirations were shallow, oxygen saturation was 87% (% - unit of measurement – normal range 95 – 100%), respiratory rate was 33 breaths per minute (bpm – unit of measurement – normal range 12 – 20 bpm), temperature was 100.7 ? (? - unit of measurement – normal range 97? to 99?), heart rate (HR) was 133 beats per minute (bpm – unit of measurement – normal range 60 – 100 bpm), BG level was 463 mg/dL, Resident 1 was administered oxygen at 15 L via non-rebreather (Face-mask for oxygen delivery) and the oxygen saturation (measures the percentage of hemoglobin in red blood cells carrying oxygen, indicating how well blood is transporting oxygen throughout the body) was at 95%.      A review of Resident 1's clinical record indicated no documented evidence that Resident 1's blood sugar levels were being checked or that the resident was being monitored for signs and symptoms of high and low blood sugars in accordance with the resident’s care plan titled “Risk For Unstable blood glucose.”      A review of Resident 1’s Situation, Background, Assessment, Recommendation (SBAR – a communication tool to relay health information) dated 2/8/2026, the SBAR indicated that Resident 1 was non-verbal, respirations were shallow, oxygen saturation was 87%, respiratory rate was 33 beats per minute, temperature was 100.7 Fahrenheit (?), heart rate was 133 bpm, BG level was 463 mg/dL. The SBAR indicated Resident 1 was administered oxygen at 15 L via non-rebreather, head of bed was elevated, and the oxygen saturation was at 95%.        A review of Resident 1’ Nursing Progress Note dated 2/8/2026 at 4:10 PM, the Note indicated that the paramedic’s (emergency responders)/911 (emergency services) was called.         A review of Resident 1’s Paramedic Run Report dated 2/8/2026, the Report indicated that Paramedic’s arrive at the facility at 4:16 PM and Resident 1 had an altered level of consciousness (ALOC), was not responding to his name. The Report indicated D5W IVF was discontinued due to Resident 1’s high BG level of 530 mg/dL, and the  electrocardiogram (devise to measure heart rhythm)  indicated Resident 1 had sinus tachycardia regular, rapid heartrate) at 130 bp