Health inspection·August 15, 2025

42 C.F.R. §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). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 42 C.F.R. §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 42 C.F.R. §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. 42 C.F.R. §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. 42 C.F.R. §483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs 22 CCR §72311Nursing Service - General (a) Nursing service shall include, but shall not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicated the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) reviewing, evaluating, and updating of the patient care plan necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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 license promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms, or behaviors exhibited by a patient. 22 CCR §72523(a) Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/23/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), who had a diagnosis of diabetes mellitus (DM) and was taking Prednisone, had her medical condition poorly managed leading to Resident 1's admission to the Intensive Care Unit (ICU) of General Acute Care Hospital (GACH) 2 with a blood sugar level (b/s) greater than 1000 milligrams ([mg] metric unit of measurement used for medication dosage and/or amount)/deciliter ([dl] a unit of measurement) (reference range of 85 mg/dl to 125 mg/dl) and a diagnosis of diabetic ketoacidosis ([DKA] a life-threatening complication of DM where the body produces too many acidic chemicals called ketones). On 6/30/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. The facility failed to: 1. Ensure licensed nurses clarified with Resident 1's physician instructions for care received from GACH 1 to check Resident 1's b/s levels every day before meals and at bedtime and for the administration of diabetic medication including insulin (a medication used to manage b/s levels in people with DM) as prescribed. According to the Policy and Procedure (P/P) titled, "Processing Physician Orders" that indicated "to process the physician orders and to clarify these orders with the attending physician to verify and maintain the accuracy of the physician orders to provide appropriate care and services." 2. Ensure Resident 1's b/s levels were monitored due to a diagnosis of DM and use of Prednisone from 4/11/2025 through 5/16/2025. 3. Ensure Resident 1's physician provided instructions for care, interventions and/or treatment to manage Resident 1's abnormal (high) blood and urine glucose (sugar) levels when Resident 1's b/s level of 378 mg/dl was obtained via a laboratory (lab) report on 5/16/2025, a glucose level of more than 1,000 mg/dl, was obtained from a urinalysis ([UA] urine test [reference range 0 to 15 mg/dl) on 5/21/2025, and a b/s level of 362 mg/dl was obtained via a lab report on 5/22/2025. 4. Notify Resident 1's physician of the resident's high b/s level of 362 mg/dl based on blood lab test report dated 5/22/2025 to obtain instructions for care, interventions and/or treatment. 5. Follow Resident 1's untitled Care Plan for DM dated 5/10/2025, to monitor Resident 1 for signs and symptoms (s/s) of hyperglycemia and hypoglycemia (low b/s level below 70 mg/dl) by checking (via a Glucometer [a machine that measures the concentration of glucose or blood sugar in a small sample of blood) Resident 1's b/s levels and rechecking as needed. 6. Develop a Care Plan for the use of Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia [a condition where there's too much sugar in the bloodstream) with interventions to monitor Resident 1 for risk, side effects, and adverse reactions related to the use of Prednisone, including elevated blood sugar levels. 7. Follow the facility's P/P titled, "Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notifications" that indicated the facility "shall promptly notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of the residents' lab results that fall outside of the clinical reference ranges because delayed notification can contribute to delays in changing the course of treatment or care plan." 8. Follow the facility's P/P titled, "Diabetes Management Policy" that indicated the facility "shall maintain the highest level of function of the residents within the normal limitations of the disease. The primary care physician orders should address medication and laboratory tests. Every resident with the diagnosis of diabetes mellitus will be identified and their care provided based on their assessed problems. Every resident should be watched for signs and symptoms of hyperglycemia and hypoglycemia including but not limited to visual disturbances, loss of skin integrity, and dehydration and should be reported to the primary care physician." As a result of these deficient practices, Resident 1 was transferred to a GACH on 6/22/2025 due to an altered level of consciousness (ALOC), hypotension, an elevated heart rate (HR), and a b/s level that indicated "high" (when the b/s level is too high to register) on the facility's glucometer. At the GACH Resident 1's b/s level was 1060 mg/dl and the resident was diagnosed with DKA with coma (a deep state of unconsciousness where a person is unresponsive to external forces and cannot be awakened) associated with DM hyperosmolar hyperglycemic state ([HHS] a serious life threatening complication of DM characterized by extremely high b/s and severe dehydration), sepsis (a life threatening condition that occurs when the body's immune system overreacts to an infection) due to urinary tract infection (UTI), and candidiasis (a fungal infection caused by an overgrowth of yeast that can occur in various parts of the body including the mouth, vagina, skin and even inside the body) of the urogenital site (a region of the body that composes of the urinary system and the reproductive system). Resident 1 was admitted to the GACH's ICU in critical condition. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, an 83-year-old female, was initially admitted to the facility on 9/21/2024 and readmitted on 4/11/2025 with diagnosis including chronic obstructive pulmonary disease (COPD) and DM. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2025, indicated Resident 1 was able to make decisions that were consistent and reasonable, required a one person assist to complete her activities of daily living (ADLs), and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions. A review of GACH 1's Preadmission Report dated 4/11/2025 and timed at 4:51 p.m., indicated Resident 1's glucose levels were routinely checked with Lispro (a type of fast acting insulin, dosage not indicated) coverage. A review of GACH 1's Reconciled Home Medications and Discharge Instructions dated 4/11/2025 and timed 3:18 p.m., indicated Resident 1 was to begin taking Prednisone 20 mg two tablets (40 mg), two times a day, DM medication and/or insulin, to ensure management of her DM. The Reconciled Home Medications and Discharge Instructions indicated a recommendation for Resident 1 to follow up with her primary care physician for b/s checks before meals and at bedtime and to inform Resident 1's physician if she showed s/s of hyperglycemia and hypoglycemia that included b/s levels over 300 mg/dl or b/s levels of less than 70 mg/dl. A review of Resident 1's Physician's Order Summary Report, dated 6/2025 indicated the following orders: 1. On 4/11/2025 - Prednisone 20 mg two tablets, two times a day for COPD. 2. On 5/10/2025 - Monitor s/s of hypoglycemia and hyperglycemia every shift and check/recheck Resident 1's b/s as needed.A review of Resident 1's Clinical Record (Physician's Orders) indicated no evidence that DM medication or insulin was prescribed and/or administered to Resident 1 after her admission to the facility on 4/11/2025. A review of Resident 1's Medication Administration Records (MAR)) dated 4/2025, 5/2025 and 6/2025, indicated the following: 1. In April 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 37 doses. 2. In May 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 59 doses. 3. In June 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 41 doses. A review of Resident 1's MARs dated 4/2025, 5/2025 and 6/2025, indicated no documented evidence that Resident 1's b/s was checked. A review of Resident 1's Care Plans in the resident's Clinical Record, indicated there was no Care Plan created related to Resident 1's use of Prednisone or interventions to monitor Resident 1 for risk, side effects, or adverse reactions associated with the use of Prednisone due to this medication ability to increase blood sugar levels. According to the Nationally recognized Cleveland Clinic, Prednisone may increase blood sugar characterized by increased thirst or amount of urine, unusual weakness or fatigue, blurry vision. https://my.clevelandclinic.org/health/drugs/20469-prednisone-tablets In patients with COPD and DM, high dose prednisone (defined as greater than 0.83 x WHO defined daily dose of prednisone of 10 mg/day) is associated with significantly higher risk of hyperglycemia and hospitalization. Comorbid Diabetes and COPD: Impact of corticosteroid use on diabetes complications - PMC A review of Resident 1's untitled Care Plan dated 5/10/2025, indicated Resident 1 had a diagnosis of DM. The Care Plan goals indicated Resident 1 would be free from any s/s of hyperglycemia and hypoglycemia and would have no complications related to DM. The Care Plan interventions included monitoring Resident 1 for s/s of hyperglycemia and hypoglycemia by checking and rechecking Resident 1's b/s levels as needed, reporting to Resident 1's physician s/s of hyperglycemia including increased thirst/appetite, fatigue, and stupor (a condition of being extremely drowsy, almost unconscious like being in a deep sleep). A review of Resident 1's Change of Condition (COC) form, dated 5/15/2025 and timed at 6:16 p.m., indicated Resident 1 had increased confusion and was not eating well. The COC indicated Resident 1's physician ordered a complete blood count ([CBC] a blood test that analyzes the different types of cells in the blood), a basic metabolic panel ([BMP] a blood test that measures several substances in the blood to assess a person's overall health and organ function including b/s) and a UA with a culture and sensitivity ([C&S] a diagnostic lab procedure used to identify the type of bacteria and to determine which medication can successfully fight an infection). A review of Resident 1's Physician's Order, dated 5/16/2025, indicated to obtain a CBC, BMP and UA with a C&S due to Resident 1's increased confusion and poor food intake. A review of Resident 1's Lab Result Report dated 5/16/2025, indicated Resident 1's b/s level was 378 mg/dl. A review of Resident 1's UA with C&S dated 5/21/2025, indicated a glucose level of more than 1,000 mg/dl in Resident 1's urine (considered a critical level). A review of Resident 1's Comprehensive Metabolic Panel [CMP] a group of blood tests that provides a broad overview of the body's chemical balance and metabolism including the kidney and liver function, blood sugar and electrolyte levels) test dated 5/22/2025, indicated Resident 1's b/s level was 362 mg/dl. A continued review of Resident 1's Clinical Records indicated there was no record of physician's care instructions based on Resident 1's elevated b/s levels, no records of monitoring Resident 1's b/s levels and/or monitoring of the resident's s/s associated with elevated b/s levels. A review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) COC 911 Transfer Form dated 6/22/2025 and timed at 10:14 a.m., indicated Resident 1 was transferred to GACH 2 because of hyperglycemia. The SBAR COC 911 Transfer Form indicated Resident 1 had decreased consciousness and only responded to tactile stimuli (direct physical contact to produce sensations of pain, pressure, vibration, temperature and pain), the resident's breathing was labored (a manner of using more effort and energy to breathe than is typical) and rapid, the resident was diaphoretic (excessive sweating) with s/s of thirst and fatigue. The SBAR COC 911 Transfer Form indicated Resident 1's HR (reference range of 60 to 100 beats per minute [bpm]) was 115 bpm, respiratory rate ([RR] reference range of 12 to 20 breaths per minute) was 26, blood pressure ([BP] reference range 120/80 millimeters of mercury ([mmhg]) was 70/89 mmhg, and the oxygen saturation rate ([O2 sat] a measurement of how much oxygen the blood is