Health inspection·October 6, 2025

F684 Code of Federal Regulations, Title 42, Section 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: California Code of Regulations, Title 22, Section 72313. Nursing Services-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. California Code of Regulations, T22, 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 8/20/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment involving Resident 1. As a result of the investigation, the Department determined the facility failed to: a. Ensure Resident 1’s physician orders were followed when Licensed Vocational Nurse 1 (LVN 1) held administration of Tresiba. b. Ensure accurate medication administration documentation for Resident 1, when LVN 2 did not document the Tresiba administration for Resident 1 on 8/9/2025. These violations resulted in medication errors and had the potential to result in serious health complications for Resident 1. a. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, an 87-year-old female, on 11/4/2018 and readmitted on 8/12/2025 with diagnoses including type 2 diabetes mellitus and unspecified hypoglycemia. A review of Resident 1’s Minimum Data Set dated 6/25/2025 indicated Resident 1’s cognitive skills for daily decision making were intact. A review of Resident 1’s Order Summary Report dated 7/1/2025 indicated Resident 1 had an order for Tresiba 55 units subcutaneous injection in the morning related to type 2 diabetes mellitus with a start date of 4/23/2025. A review of Resident 1’s Medication Administration Record dated 7/1/2025 -7/31/2025 and 8/1/2025 - 8/31/2025, indicated the 6:30 AM dose for Tresiba 55-unit[s] subcutaneous injection were held on 7/11/2025, 7/12/2025, 7/18/2025, 7/23/2025, 7/29/2025, 7/30/2025, 8/2/2025, and 8/6/2025 by LVN 1. A review of Resident 1’s Progress Notes (PN) dated 7/11/2025 at 5:43 AM indicated Resident 1’s blood sugar (BS) was 97 and Tresiba was held for safety. A review of Resident 1’s PN dated 7/12/2025 at 7:05 AM indicated Resident 1’s BS was not documented and Tresiba was held because the BS was very low. A review of Resident 1’s PN dated 7/18/2025 at 7:21 AM indicated Resident 1’s BS was 140 and Tresiba was held because too much insulin would have dropped the BS very low. A review of Resident 1’s PN dated 7/23/2025 at 5:34 AM indicated Resident 1’s BS was 117 and Tresiba was held because 55 units of medication would be too much for this level and the medication was held for safety. A review of Resident 1’s PN dated 7/29/2025 at 6:21AM indicated Resident 1’s BS was 116 and Tresiba was held because 55 units would drop the resident’s BS very low. A review of Resident 1’s PN dated 7/30/2025 at 5:37 AM indicated Resident 1’s BS was 155 and Tresiba was held to prevent the BS level to drop below normal range. A review of Resident 1’s PN dated 8/2/2025 at 5:40 AM indicated Resident 1’s BS was 125 and Tresiba was held because Resident 1’s BS was within normal limits. A review of Resident 1’s PN dated 8/6/2025 at 6:46 AM indicated Resident 1’s BS was 76 and Tresiba was held for safety purposes. A review of Resident 1’s Care Plan (CP) titled “(Resident 1) has diabetes mellitus,” initiated 4/29/2025, revised 8/13/2025 indicated Resident 1 will have no complications related to diabetes mellitus. The CP interventions indicated licensed nursing staff to administer diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness. During a telephone interview on 8/20/2025 at 3:44 PM with LVN 1, LVN 1 stated LVN 1 would hold Resident 1’s 6:30 AM dose of Tresiba 55 units if Resident 1’s blood sugar level was below 170 milligrams per deciliter (mg/dL).  LVN 1 stated Resident 1’s physician’s order for Tresiba did not indicate the Tresiba should be held if Resident 1’s blood sugar was below 170 mg/dL. LVN 1 stated LVN 1 notified the Registered Nurse Supervisor (RN 1) that LVN 1 held the Tresiba medication for Resident 1. During a telephone interview on 8/20/2025 at 4:30 PM with RN 1, RN 1 stated LVN 1 informed RN 1 that LVN 1 held the Tresiba Medication for Resident 1. RN 1 stated the doctor was not notified when Resident 1’s Tresiba was held by LVN 1. During an interview on 8/21/2025 at 12:25 PM with the Director of Nursing (DON), the DON stated if a physician’s order did not indicate a medication was to be held, it was the facility’s policy for the licensed staff to get a doctor’s order prior to holding the administration of a medication. b. During an interview on 8/20/2025 at 12:53 PM with Resident 1, Resident 1 stated on the morning of 8/9/2025 LVN 2 administered Tresiba 55 units to Resident 1. During a telephone interview on 8/20/2025 at 3:37 PM with LVN 2, LVN 2 stated on 8/9/2025 at 5:40 AM, LVN 2 administered Tresiba 55 units to Resident 1. During a concurrent interview and record review on 8/21/2025 at 12:25 PM with the DON, Resident 1’s MAR dated 8/1/2025-8/31/2025 was reviewed. The MAR indicated the 6:30 AM dose for Tresiba 55-unit[s] subcutaneous injection on 8/9/2025 was not administered. The DON stated LVN 2 should have documented the 6:30 AM dose of Tresiba was administered by LVN 2 on 8/9/2025 in Resident 1’s MAR. A review of the facility’s undated Policy and Procedure (P&P) titled, “Medication Administration,” indicated medications will be administered as prescribed by the physician.  The P&P’s medication administration process indicated that the person administering the medication was to initial the resident’s medication sheet in the provided space under the appropriate date and time for that particular dose administered. The P&P’s medication administration process indicated documentation on the medication sheet needed to be done immediately following administration. The facility failed to: a. Ensure Resident 1’s physician orders were followed when LVN 1 held administration of Tresiba. b. Ensure accurate medication administration documentation for Resident 1, when LVN 2 did not document the Tresiba administration for Resident 1 on 8/9/2025. These violations resulted in medication errors and had the potential to result in serious health complications for Resident 1. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.