Health inspection·May 9, 2025

F635 At the time each resident is admitted, the facility must have physician orders for the resident's immediate care. To ensure each resident receives necessary care and services upon admission. Code of Federal Regulations, Title 42, Section 483.21 (a)(1) Baseline Care Plans

F655 The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must— (i) Be developed within 48 hours of a resident’s admission. Code of Federal Regulations, Title 42, Section 483.21 (b)(1) Comprehensive Care Plans

F656 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 (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 — §483.21(b)(3) Comprehensive Care Plans

F658 The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— (i) Meet professional standards of quality. Code of Federal Regulations, Title 42, Section 483.25 Quality of care

F684 Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients’ choices[.] Code of Federal Regulations, Title 42, Section 483.30(b) Physician Visits (b) The physician must - (1) Review the resident’s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. California Code of Regulations., Title 22, Section 72311. Nursing Service - General. (a) Nursing service shall include, but 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. (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 licensure promptly of: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). California Code of Regulations, Title 22, Section 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. (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. California Code of Regulations, Title 22, Section 72523. 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 3/25/25 at 8:50 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding a resident’s death. As a result of the investigation, it was determined that, the facility failed to ensure Resident 1, who had a diagnosis of Diabetes Mellitus (DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin [a hormone that regulates blood sugar levels in the body]) and history of hypoglycemia (a condition were blood sugar levels drop below normal), received treatment and services, in accordance with professional standards of practice, the care plan, and physician orders for the management of DM and hypoglycemia. The facility failed to: 1. Ensure Registered Nurse (RN) 2 reviewed Resident 1's General Acute Hospital (GACH) 2 Records on 2/14/2025, for all appropriate GACH 2 discharge orders and ensure readmission orders from GACH 2 and continuity of care for DM was verified with the facility's attending physician (Medical Doctor [MD] 1) or the facility's Nurse Practitioner (NP 1), upon readmission back to the facility on 2/14/2025, in accordance with the facility’s policy & procedures (P&P) titled “Reconciliation of Medications on Admission.” 2. Ensure the facility's licensed staff (RN 2 and Licensed Vocational Nurse [LVN] 3) reviewed Resident 1's medical history of DM and history of hypoglycemic episode, requiring transfer to GACH 2 on 2/10/2025, and was previously receiving blood sugar (BS) monitoring (the process of regularly checking and measuring the levels of blood sugar), prior to readmission to the facility to ensure continuity of diabetic care and management, on 2/14/2025 to 2/18/2025. 3. Ensure Resident 1's care plan for DM was implemented by monitoring Resident 1 for hypoglycemia and hyperglycemia (a condition in which a person's blood sugar level is higher than normal) while residing at the facility from 2/14/25 to 2/18/25 (5 days). 4. Inform or verify with MD 1 or NP 1 on 2/17/2025 that Resident 1's GACH 2 Discharge Summary orders dated 2/14/2025 for BS monitoring before meals and at bedtime, including a routine insulin injection (Insulin Glargine [a long acting insulin used to manage blood sugar levels]) at bedtime was not ordered upon the resident's readmission back to the facility on 2/14/2025, to manage the resident's DM. LVN 3 failed to obtain an order from MD 1 or NP 1 prior to entering an order for 10 units of routine insulin injection to be administered at bedtime on 2/17/2025, three days after the resident's readmission to the facility. Additionally, LVN 4 failed to check Resident 1's blood sugar before administering the newly entered order of routine insulin injection on 2/17/2025 at bedtime to Resident 1, in accordance with Resident 1's care plan for DM and the facility’s Policies and Procedures (P&P) on Physician Orders. 5. Ensure LVN 1 and LVN 2 performed adequate assessment of Resident 1's condition on 2/18/2025 and notified MD 1 or NP 1 of Resident 1's altered level of consciousness (ALOC - a change in a patient's state of awareness [ability to relate to self and the environment]), blood sugar of 27 (normal blood sugar levels are between 70 to 100) and low blood pressure (undocumented) on 2/18/2025 and called 911 emergency services, in accordance with professional standards of practice and recommended guidelines for residents with hypoglycemia. 6. Ensure LVN 1 and LVN 2 administered glucagon (used along with emergency medical treatment to treat very low blood sugar) intramuscularly ([IM] injection under the muscle) to Resident 1 on 2/18/2025, instead of oral glucose gel and orange juice to raise Resident 1’s blood sugar due Resident 1’s ALOC and inability to follow directions and swallow, in accordance with the facility’s P&P titled “Conformity with Laws and Professional Standards” and the facility provided document titled “Hypoglycemia Recommended Guidelines." 7. Ensure LVN 1, LVN 2, and NP 1 called 911 Emergency Services (EMS - provides Advance Life Support [ALS- refers to a medical service that provides advanced medical care to critically ill or injured patients during transport to a healthcare facility]), instead of a Basic Life Support (BLS) Emergency (provides essential pre-hospital medical care and transportation for patients who are not in a critical condition, focusing on basic interventions and is staffed by trained EMTs) transport on 2/18/2025, due to Resident 1’s ALOC with severely low blood sugar, in accordance with the facility’s P&P titled “Conformity with Laws and Professional Standards. The BLS EMTs arrived at Resident 1’s room on 2/18/2025 at 2:15 PM and refused to take Resident 1 due to severe hypoglycemia, hypotension (abnormally low blood pressure level) with blood pressure of 80/44 mm/Hg, and decreased mental status from baseline. LVN 2 called 911 EMS on 2/18/2025, around 3 PM. The GACH 3 ED record indicated Resident 1 arrived at the GACH 3 via 911 emergency services on 2/18/2025 at 3:04 PM. The above violations resulted to Resident 1’s change in condition (CIC) and delay of critical care on 2/18/2025, when the situation presented as a medical emergency due to Resident 1’s ALOC, hypoglycemia with a BS of 27, and hypotension. Resident 1 was transferred to GACH 3 via 911 EMS on 2/18/2025 and admitted to the Intensive Care Unit (ICU - provides the critical care and life support for acutely ill and injured patients). Resident 1 died at GACH 3 on 3/4/2025. A review of Resident 1's Admission Record (AR), documented that Resident 1 was admitted to the facility on 9/5/2024 and readmitted to the facility on 2/14/2025 with diagnoses that included pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid), sepsis (a serious condition in which the body responds improperly to an infection), respiratory failure (a serious condition that makes it difficult to breathe on your own), DM Type 2, cerebral infarction (when a blood vessel in the brain is blocked, preventing blood and oxygen from reaching the brain tissue, leading to cell death), and End Stage Renal Disease (ESRD- a condition in which the kidneys have lost most of their function and are no longer able to adequately filter waste products, excess fluids, and electrolytes from the blood). A review of Resident 1's Physician Telephone Order (TO) dated 2/1/2025 timed at 1:44 AM, indicated, "Insulin Lispro (a fast acting type of insulin) injection solution, inject as per insulin sliding scale (ISS - a chart of insulin dosages preordered for each blood sugar result): 2 units for BS of 150 - 199 [mg/dL], 4 units for BS of 200 - 249 [mg/dL], 6 units for BS of 250 - 299 [mg/dL], 8 units for BS of 300 - 349 [mg/dL], and 10 units for BS of 350 - 399 [mg/dL], "Subcutaneously (SC-beneath the skin) at bedtime for Antidiabetics, before meals." A review of Resident 1's Physician TO dated 2/1/2025 timed at 2:01 AM, indicated an order to admit Resident 1 under the care of MD 1. A review of Resident 1's Nurses Progress Notes dated 2/1/2025 documented at 3:08 AM, indicated Resident 1 was readmitted back from GACH 1. The Note indicated Resident 1 was alert and oriented. A review of Resident 1’s Medication Administration record (MAR) indicated a start date of 2/1/2025 and discontinued (DC) date of 2/14/2025. The MAR showed the licensed nurses monitored Resident 1's blood sugar with Lispro ISS injection of 2 units for BS of 150 – 199 [mg/dL], 4 units for BS of 200 - 249 [mg/dL], 6 units for BS of 250 - 299 [mg/dL], 8 units for BS of 300 - 349 [mg/dL], and 10 units for BS of 350 - 399 [mg/dL], "Subcutaneously at bedtime for Antidiabetics, before meals" from 2/1/25 to 2/9/2025. The MAR indicated the code "HO" which indicated Resident 1 was "Hospitalized" from 2/10/2025 to 2/14/2025. A review of Resident 1's MAR for February 2025, indicated Resident 1 was on insulin Glargine solution (long-acting form of insulin), inject 10 units SC at bedtime [9 PM] for DM. The MAR indicated Resident 1 received one dose of Insulin Glargine 10 units routinely every 9 PM from 2/1/2025 to 2/09/2025. The MAR indicated the code "HO" which indicated Resident 1 was "Hospitalized" from 2/10/2025 to 2/14/2025. A review of Resident 1's MAR indicated a start date of 2/1/2025 and DC date of 2/14/2025, indicated Resident 1 was on Metformin Hydrochloride (HCL) (a medicine taken by mouth to treat type 2 diabetes) oral tablet 1000 mg, one tablet by mouth two times a day for "Antidiabetic." A review of Resident 1's Nurses Progress Notes dated 2/10/2025 documented at 10:30 AM, indicated Resident 1 was observed with ALOC staring at the ceiling, with cold clammy skin, BS was at 60 [mg/dL] with oxygen saturation (measures the percentage blood that is carrying oxygen - with normal levels between 95 to 100%) of 80%. The Note indicated the physician was notified and ordered the licensed nurse to transfer Resident 1 to the GACH via 911 EMS. The Note indicated EMS arrived on 2/10/2025 at 10:45 AM and transferred Resident 1 to GACH 2 for ALOC. A review of Resident 1's Physician TO dated 2/10/2025 timed at 10:40 AM, indicated an order to transfer the resident to GACH 2 for ALOC. A review of Resident 1's GACH 2 records titled "Discharge Summary" dated 2/14/2025, indicated Resident 1's "discharge medications" that included "Insulin Glargine solution, inject 10 units subcutaneously (SC-beneath the skin) at bedtime" and "Insulin lispro, 0 units SC before meals and at bedtime." A review of Resident 1's History and Physical Examination (HPE) from the facility, dated 2/14/2025 and signed by Resident 1's attending physician (MD 1), indicated the resident had the capacity to understand and make decisions. The HPE indicated a handwritten "Plan" for Resident 1 that included blood sugar checks before meals and at bedtime with ISS and "low dose insulin," Hemodialysis (a treatment to filter waste and water from the blood) Mondays, Wednesdays and Fridays, fall precautions, and medication reconciliation. A review of Resident 1's Nurses Progress Notes dated 2/14/2025 documented at 7:36 PM by RN 2, indicated Resident 1 was readmitted back to the facility from GACH 2 due to altered mental status and metabolic acidosis (develops when too much acid is produced in the body). A review of Resident 1's Physician TO dated 2/14/2025 documented at 8:16 PM, indicated an order to admit Resident 1 under the care of MD 1. A review of Resident 1's Physician TO dated 2/14/2025 documented at 8:21 PM, indicated an order for: "Insulin Lispro injection solution, inject as per sliding scale (ISS): 2 units for BS of 150 - 199, 4 units for BS of 200 - 249, 6 units for BS of 250 - 299, 8 units for BS of 300 - 349, and 10 units for BS of 350 - 399, "Subcutaneously at bedtime for Antidiabetics, before meals." The order further indicated the BS monitoring was discontinued on 2/14/2025 timed at 11:20 PM. A review of Resident 1's TO dated 2/15/2025 documented at 1:43 AM and entered by RN 2 in Resident 1's electronic record, indicated Resident 1 to be readmitted back to the facility. Further review of Resident 1's TO indicate no evidence of blood sugar monitoring ordered for Resident