Health inspection·March 6, 2025

42 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: 22 CCR § 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. 22 CCR § 72523(a) Patient Care Policies and Procedure. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/17/2025, the California Department of Public Health (CDPH) received a complaint regarding quality of care. On 1/28/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation CDPH determined the facility failed to: 1. Ensure Resident 1’s Medical Doctor (MD) ordered blood glucose monitoring for Resident 1 to ensure the Empagliflozin (blood sugar level regulating medication) was effective and to prevent Resident 1 from developing hyperglycemia (high blood sugar) or hypoglycemia (occurs when the blood glucose [simple sugar-body’s primary source of energy/food] level drops below the level the body can function with normally) . 2. Ensure the Nurse Practitioner (NP) had knowledge of Resident 1’s diagnosis of type 2 diabetes ([diabetes mellitus] body’s inability to regulate blood sugar levels leading to poor wound healing) and ordered Resident 1’s blood glucose (sugar) monitoring. 3. Ensure Licensed Vocational Nurse (LVN) 3 was aware of Resident 1’s diagnosis of type 2 diabetes to deliver care, accordingly, including monitoring the resident for signs and symptoms of hyperglycemia or hypoglycemia. 4. Ensure LVN 1 and LVN 3 contacted Resident 1’s MD to alert the MD of the lack of an order for Resident1’s blood glucose monitoring. 5. Ensure the Director of Nursing (DON) clarified Resident 1’s orders with Resident 1’s MD and NP to ensure Resident 1 was properly monitored for blood glucose level to prevent the resident from developing hyperglycemia or hypoglycemia. 6. Ensure the licensed nurses developed a plan of care for Resident 1’s diagnosis of diabetes and intake of Empagliflozin, blood glucose lowering medication, to have interventions in place for resident’s glucose monitoring and signs and symptoms of hyperglycemia or hypoglycemia. 7. Ensure staff followed the facility’s policy and procedure (P&P) titled, “Diabetes Mellitus, Resident, Nursing Care of” revised November 2017, which indicated “the policy of the facility was to recognize and assist in the treatment of complications commonly associated with diabetes. The policy indicated the facility will document pertinent laboratory studies including blood sugar.” On 12/17/2024, Resident 1 was transferred via 911 (emergency medical transportation) due to altered level of consciousness (not fully responsive to environment) to the General Acute Care Hospital (GACH) where he was found to have a blood sugar level of 595 milligrams per deciliter ([mg/dl -unit of measurement]; reference range 70 mg/dl to 99 mg/dl) upon admission with a diagnosis of diabetic ketoacidosis (life-threatening complication of diabetes that occurs when the blood sugar levels are too high and untreated for a prolonged length of time). As a result of these deficient practices Resident 1 had an altered level of consciousness due to very high blood sugar levels leading to diabetic ketoacidosis which had the potential to lead to a diabetic coma (a condition when the body is overwhelmed with the amount of blood sugar levels, and the resident cannot wake up or respond purposefully to the environment) and death. Findings: A review of Resident 1’s a 73-year-old male’s Admission Record indicated Resident 1 was admitted to the facility on 12/11/2024 with diagnoses including type 2 diabetes mellitus, occlusion (blockage) of left carotid artery (vessel that supplies head and neck with blood) and atherosclerotic heart disease (blockages in vessels that supply the heart with blood). A review of Resident 1's Minimum Data Set ([MDS] – a resident assessment tool), dated 12/17/2024, indicated Resident 1’s cognitive (the mental process of thinking, learning, remembering, and using judgement) skills for daily decision-making were moderately impaired. A review of Resident 1’s Order Summary Report (physician’s orders) dated 12/12/2024 indicated an order for Empagliflozin Oral Tablet 10 milligrams ([mg]-unit of measurement) one tablet daily for diabetes mellitus. A review of Resident 1’s Medication Administration Record (MAR) dated from 12/1/2024 through 12/31/2024, indicated Resident 1 received Empagliflozin 10 mg on 12/12/2024, 12/13/2024, 12/15/2024, 12/16/2024 and 12/17/2024 as ordered. A review of Resident 1’s Change of Condition (COC), dated 12/17/2024 and timed at 1:54 p.m., indicated Resident 1 had signs and symptoms of altered mental status (a significant change in mental function), hypotension (low blood pressure [force exerted by your blood pushing against the walls of your arteries as your heart pumps blood throughout your body]) and hyperglycemia. The COC indicated Resident 1’s systolic blood pressure [pressure of blood in your arteries when the heart beats] was 90 millimeters of mercury ([mmHg – unit of measure] reference range 90 -120mm Hg). The COC indicated the facility staff notified Resident 1’s NP and the NP ordered for Resident 1 to be transferred to the GACH via 911. A review of Resident 1’s MAR dated 12/17/2024 indicated a physician’s order dated 12/17/2024 and timed at 2:04 p.m. to give Lispro Insulin (quick acting medicine used to lower blood sugar) 15 Units (unit of measurement) STAT (immediately) for hyperglycemia one time only. A review of Resident 1’s Follow up Skilled NP Progress Notes, dated 12/17/2024 and timed at 1 p.m., indicated Resident 1 was hyperglycemic, when the residents’ blood sugar level was checked and 15 units of Lispro insulin was administered but Resident 1’s blood sugar remained high (unspecified) after administration and Resident 1 was lethargic (a state of being drowsy and dull, listless, unenergetic, indifferent, sluggish and inactive) with blood pressure at 71/56 mmHg. The Skilled NP Progress Notes indicated nursing staff was advised to transfer Resident 1 via 911 to the GACH. A review of Resident 1’s GACH Emergency Room Note, dated 12/17/2024 and timed at 2:08 p.m., indicated Resident 1 was sent to the GACH from the facility due to high blood sugar (unspecified), causing diabetic ketoacidosis and low blood pressure of 81/45. The GACH Emergency Room Note indicated Resident 1’s blood glucose level on 12/17/2024 at 2:30 p.m., was 595 mg/dl (reference range 70 mg/dl to 99 mg/dl). The note indicated Resident 1 was admitted with the diagnosis of diabetic ketoacidosis. During an interview on 1/28/2025 at 11:50 a.m., Licensed Vocational Nurse (LVN) 3 stated, on 12/17/2025 she was assigned to care for Resident 1. LVN 3 stated on 12/17/2024 Resident 1’s caregiver called her to Resident 1’s bedside. LVN 3 stated upon arrival to Resident 1’s room, Resident 1 appeared to have a decreased level of consciousness. LVN 3 stated, the care giver asked her (LVN 3) what Resident 1’s blood sugar readings were. LVN 3 stated, she informed the care giver she did not know Resident 1 was diabetic needing blood sugar checks. LVN 3 stated, she told Resident 1’s caregiver that the resident’s blood sugar had not been monitored (since admission on 12/11/2024 [eight days]) because there was no physician’s order to monitor Resident 1’s blood sugar. LVN 3 stated Resident 1 was transferred to the GACH via 911 on 12/17/2024. During an interview on 1/28/2025 at 11:30 p.m., the facility consultant pharmacist (Pharm) stated Empagliflozin is medication used to lower the sugar level in the blood. The Pharm stated residents should have their blood sugar levels monitored regularly (not specified) to determine the residents’ response to Empagliflozin. The Pharm stated failure to monitor resident’s blood sugar level places residents at risk of having undetected hyperglycemia and hypoglycemia. The Pharm stated without blood glucose monitoring, we cannot adequately assess the effectiveness of blood sugar lowering medication. During an interview on 1/28/2025 at 2 p.m., Resident 1’s NP stated she did not order Resident 1’s blood glucose monitoring because she did not know he had type 2 diabetes. The NP stated she had limited clinical documentation to review upon Resident 1’s arrival and may have missed important information pertaining to Resident 1’s medical history. The NP stated the facility nursing staff did not call her to clarify the need for blood sugar checks since Resident 1 was a diabetic. The NP stated she would have ordered blood glucose checks if they had. The NP stated she only found out of Resident 1’s diagnosis of diabetes from Resident 1’s home care giver, who was at Resident 1’s bedside at the time Resident 1 was already hyperglycemic. During an interview on 1/29/2025 at 8:45 a.m., Resident 1’s Medical Doctor (MD) stated he did not assess Resident 1 during Resident 1’s stay at the facility. The MD stated he delegated Resident 1’s care to his NP. The MD stated, on 12/17/2024 upon learning Resident 1 was receiving Empagliflozin he would have ordered blood glucose monitoring to ensure the medication was effective for Resident 1. The MD stated Resident 1 was at risk for hyperglycemia and hypoglycemia which the nursing staff should be assessing for in addition to regular blood glucose level testing. The MD stated failure to monitor for signs and symptoms of hyperglycemia and hypoglycemia placed Resident 1 at risk for a decline of health, diabetic ketoacidosis, diabetic coma, and possible death. During an interview on 1/29/2025 at 11:55 a.m., LVN 1 stated on 12/12/2024 and 12/13/2024, she administered Empagliflozin to Resident 1. LVN 1 stated Empagliflozin is a medication to lower blood sugar. LVN 1 stated it is important to know the resident’s blood sugar level prior to administering Empagliflozin to ensure the resident is not hypoglycemic or hyperglycemic. LVN 1 stated although it is important to assess Resident 1’s blood sugar prior to administrating Empagliflozin, she did not see a physician’s order to check Resident 1’s blood sugar level and did not think to question the lack of physician’s order for blood sugar testing. During an interview on 1/29/2025 at 4 p.m., the DON stated it was her responsibility to ensure all newly admitted residents’ clinical documents were reviewed to ensure residents receive the appropriate care and treatments. The DON stated she was aware Resident 1 had diabetes and did not have a physician’s order for blood glucose monitoring. The DON stated, she assumed the physician care team (MD and NP) knew Resident 1 had type 2 diabetes. The DON stated she should have clarified the orders with Resident 1’s care team to ensure Resident 1 was properly monitored for complications of hypoglycemia and hyperglycemia. The DON stated upon review of Resident 1’s clinical documentation, there was no care plan developed to address Resident 1’s diabetic care. The DON stated a diabetic care plan would address monitoring resident’s blood sugar as directed by the physician, appropriate diabetic diet, monitoring signs and symptoms of hyperglycemia and or hypoglycemia. The DON stated Resident 1 should have had a care plan in place to ensure Resident 1 was being monitored for complications of diabetes. A review of the Medication Guide for Empagliflozin, undated, indicated Empagliflozin can cause serious side effects including diabetic ketoacidosis. A review of an online article from American Diabetic Association (a nonprofit organization the funds research to prevent, cure and manage diabetes) website titled “Diabetes and Diabetic Ketoacidosis (DKA),” indicated DKA is a life-threatening condition that can lead to diabetic coma and even death. The article indicated treatment for DKA takes place in the hospital, but it can be prevented by learning the warning signs and by checking blood glucose regularly. The early symptoms include thirst, frequent urination and high blood sugar level. https://diabetes.org/ A review of the online article from American Diabetic Association website titled “Treatment and Care, check your Blood Glucose (sugar), Diabetic Testing and Monitoring” indicated blood sugar monitoring is the primary tool used to find out if blood glucose levels are within range. https://diabetes.org/ A review of the facility’s P&P titled, “Diabetes Mellitus, Resident, Nursing Care of” revised November 2017, the P&P indicated the policy of the facility is to recognize and assist in the treatment of complications commonly associated with diabetes. The policy indicated the facility will document pertinent laboratory studies including blood sugar. A review of the facility’s Job Description “Director of Nursing” Revised October 2021 indicated the DON would assist in the management and direction of the Nursing Department in accordance with federal, state and local standards, guidelines and regulations that govern the facility and as may be directed by the Administrator and Medical Director, to ensure the highest degree of quality of care is always maintained. The job description indicated the DON would communicate information to nursing personnel regarding new resident admissions and resident discharges and provide oversight. The job description indicated the DON would develop a written plan of care (preliminary and comprehensive) for each resident with identified problems/needs, which indicates the care to be given, goals to be accomplished and which professional service is responsible for each element of care. The facility failed to: 1. Ensure Resident 1’s MD ordered blood glucose monitoring for Resident 1 to ensure the Empagliflozin was effective and to prevent Resident 1 from developing hyperglycemia or hypoglycemia. 2. Ensure the NP had knowledge of Resident 1’s diagnosis of type 2 diabetes and ordered Resident 1’s blood glucose monitoring. 3. Ensure LVN 3 was aware of Resident 1’s diagnosis of type 2 diabetes to deliver care, accordingly, including monitoring the resident for signs and symptoms of hyperglycemia or hypoglycemia. 4. Ensure LVN 1 and LVN 3 contacted Resident 1’s MD to alert the MD of the lack of an order for Resident1’s blood glucose monitoring. 5. Ensure the DON clarified Resident 1’s orders with Resident 1’s MD and NP to ensure Resident 1 was properly monitored for blood glucose level to prevent the resident from developing hyperglycemia or hypoglycemia. 6. Ensure the licensed nurses developed a plan of care for Resident 1’s diagnosis of diabetes and intake of Empagliflozin, blood glucose lowering medication, to have interventions in place for resident’s glucose monitoring and signs and symptoms of hyperglycemia or hypoglycemia. 7. Ensure staff followed the P&P titled, “Diabetes Mellitus, Resident, Nursing Care of” revised November 2017, which indicated “the policy of the facility was to recognize and assist in the treatment of complications commonly associated with diabetes. The policy indicated the facility will document pertinent laboratory studies including blood sugar.” This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.