Other·April 27, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a complaint investigation. Complaint Intake Number: CA00558971 Substantiated with regulatory violations. Representing the Department: HFEN # 36290 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of the entity reported incident 558971.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 04/06/2018 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 1 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055247 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY OAKS CARE CENTER 215 W Pearl St Pomona, CA 91768 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1) by failing to: 1. Obtain a physician's order for insulin (a medication used to control high blood sugar). 2. Implement interventions in the plan of care, dated 6/15/17, to treat Resident 1's diabetes mellitus (DM, a disorder that causes high blood sugar) type two (the body needs insulin to keep the blood sugar at normal levels). 3. Identify the irregularities in list of discharged medications from the general acute care hospital (GACH 1) at readmission during the medication reconciliation (the process of comparing a patient's medication orders to all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 2 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055247 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY OAKS CARE CENTER 215 W Pearl St Pomona, CA 91768 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of the medications that the patient has been taking to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions) at the facility and by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident). Resident 1 had been receiving insulin at the facility for four months prior to the transfer to GACH 1. After readmission to GACH 1 on 10/13/17, the resident did not receive insulin up to 10/31/17 (for 18 days). The IDT met on 10/19/17 and concluded to continue the June 2017 care plan, which contained interventions to administer insulin and conduct blood sugar monitoring, but the IDT failed to identify the irregularities in the resident's medication regimen. This deficient practice resulted in Resident 1 being transferred to a general acute care hospital 1 (GACH 1) and developing diabetic ketoacidosis (DKA, a life threatening condition that develops when the body does not have enough insulin to process the blood sugars). Findings: A review of Resident 1's Record of Admission indicated the resident was originally admitted to the facility, on 6/15/17. Resident 1 was admitted with diagnoses that included DM, chronic respiratory failure, and dependence on respiratory ventilator (a machine used for breathing and delivering oxygen). A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 6/22/17, indicated Resident 1's cognitive (understanding) skills of daily decision making was severely impaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 3 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055247 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY OAKS CARE CENTER 215 W Pearl St Pomona, CA 91768 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Physician Admission Orders, dated 6/15/17, indicated a physician's order for the resident to receive 30 units of Insulin Detemir every night (HS). The physician also ordered blood sugar monitoring every twelve hours and a sliding scale (additional insulin dose given based on the blood sugar level in milligrams per deciliter or mg/dL, the higher the blood sugar the more insulin was administered) with Humalog Regular. The sliding scale order indicated to administer Humalog Regular (in units) as follows: Blood sugar range - 60 to 150 - 151 to 200 - 201 to 250 - 251 to 300 - 301 to 350 - 351 to 400 - greater than 400 Units of Humalog Regular 0 2 4 6 8 10 12 The physician's order indicated for the staff to notify the physician for a blood sugar less than 60 mg/dL (milligram per deciliter) or greater than 400 mg/dL. A review of Resident 1's care plan, dated 6/15/17 and titled, "Insulin Dependent Diabetes Mellitus," indicated the goal for the resident was for her blood sugar within acceptable range daily to prevent complications. The interventions included monitoring blood sugars by finger stick per orders and notifying the physician of significant changes; administering oral medication and insulin per orders; and administering Insulin Detemir and insulin sliding scale, and finger stick blood sugar (FSBS) check every 12 hours A review of Resident 1's Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 4 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055247 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY OAKS CARE CENTER 215 W Pearl St Pomona, CA 91768 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Administration Records (MAR) indicated that from 6/17/17 to 10/4/17, Resident 1 received 30 units of Insulin Detemir every night and one (1) unit to 10 units of Humalog Regular Insulin following the ordered sliding scale. A review of Resident 1's Interact Resident Transfer, dated 10/5/18, indicated resident was transferred to GACH 1 for further evaluation and transfusion (receive blood intravenously). A review of GACH 1's Medication Discharge Summary Report indicated the hospital followed an insulin sliding scale for Resident 1. Resident 1 received regular insulin sliding scale on 10/9/17, 10/11/17, 10/12/17, and 10/13/17. A review of Resident 1's list of medications from Discharge Care Plan from GACH 1, which had an instruction to continue the medications on the list, did not include insulin. A review of Resident 1's Record of Admission indicated resident was readmitted to the facility on 10/13/17. A review of Resident 1's Physician Admission Orders/Medication Record, dated 10/13/17 at 7:40 p.m., indicated no physician order for Insulin. A review of Resident 1's MAR, from 10/13/17 to 10/31/17, indicated no Insulin treatment for Resident 1's DM. A review of the facility's additional comments in the Resident 1's Admission Assessment, dated 10/13/17 indicated that Resident 1 was under the care of Physician 1 but that Physician 2, who was on call for Physician 1, verified and approved the hospital's list (medication reconciliation that includes discontinued and continued medications) of medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 5 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055247 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY OAKS CARE CENTER 215 W Pearl St Pomona, CA 91768 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Physician 2 gave orders to continue the medications. On 11/01/17 at 9:55 a.m., an interview was conducted with the responsible party (RP). The RP stated that Resident 1 was diabetic and received Insulin for more than 30 years. The RP stated that when Resident 1 was originally admitted on 6/15/17 to the facility, an IDT meeting was held and the RP and the IDT discussed all of Resident 1's medications (including Insulin). During the interview, the RP stated that when Resident 1 was readmitted to the facility, she was responsive and alert but as days went by, Resident 1's level of alertness decreased and no longer opened her eyes, attempted to sing along, or assisted by holding the bed's side bar. The RP stated that on 10/31/17, Resident 1 was unresponsive, lethargic, and wouldn't open her eyes and the facility did not administer Insulin to help control/lower Resident 1's blood sugar since the 10/13/17 readmission. On 11/01/17 at 10:55 a.m., during an interview, the Licensed Vocational Nurse 1 (LVN 1) stated that the facility did not monitor Resident 1's blood sugar, on 10/13/17, readmission, because the "Doctor did not order it," and the facility administered medications and monitored blood sugars when the physician wrote the order. On 11/25/17 at 8:12 a.m., during an interview, the Registered Nurse (RN) 1 stated readmission documents for resident included all medications (continued and discontinued) from the hospital, and the nurse then called the physician to share the list of medications. RN 1 stated when the physician approved the continued medications, the nurse transcribed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 6 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055247 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY OAKS CARE CENTER 215 W Pearl St Pomona, CA 91768 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the continued medications to the resident's admission orders. RN 1 stated not all licensed nurses compare previous medication orders in the facility with the new readmission medication orders. On 11/25/17 at 10:32 a.m., during an interview, the Assistant Director of Nursing (ADON) stated when a resident was readmitted to the facility, it was not the facility's practice for the nurses to obtain the old chart to compare old with newly ordered medications. The nurses would get the hospital report that included the medication reconciliation, call the primary physician and verify the reconciliation. The ADON stated that Resident 1 did not receive insulin because it was not included in the GACH 1's medication reconciliation. A review of the readmission Resident Care Conference Review (IDT) dated 10/19/17 indicated that one Licensed Vocational Nurse (LVN), the dietary supervisor, a social service staff, and the case manager attended the meeting. The areas that were reviewed included: physician's orders, diagnosis, and care planning. Resident 1 was not able to attend the meeting because she was "unable to verbalize needs [due to cognitive] impairment. The responsible party did not attend the meeting (the notification portion was left blank). The IDT indicated that there were no significant changes for Resident 1 and the June 2017 plan of care was to be continued. A review of Resident 1's Diagnostic Laboratories results indicated that Resident 1's glucose (blood sugar) were 230 mg/dL on 10/20/17, 316 mg/dL on 10/26/18, and 295 mg/dL on 10/27/18. There were no documented evidence that the physician was made aware of the glucose results. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 7 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055247 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY OAKS CARE CENTER 215 W Pearl St Pomona, CA 91768 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Nursing Progress Notes, dated 10/31/17 at 9:30 a.m., indicated that the facility made the RP aware that Resident 1 was not being administered insulin or getting blood sugar checked because there was no physician's order. The RP notified the facility that Resident 1 had been diabetic for 35 years. The RP made a request to the charge nurse to check Resident 1's blood sugar. Resident 1's blood sugar was greater than 400 mg/dL. The physician was notified and a new order for Humulin Regular (insulin medication) 10 units to be given STAT (urgent) for the high blood sugar, Dextrose 5% Normal Saline (intravenous sugar solution) at 50 milliliters per hour for hydration, and transfer to the hospital's emergency room for evaluation of uncontrolled blood sugar. At 12 p.m., Resident 1's blood sugar was 393 and at 1:25 p.m., the ambulance picked up the resident. A review of the hospital's Emergency Department (ED) Course notes and report of physical exam, dated 10/31/17, indicated Resident 1 was admitted with diagnoses that included aspiration pneumonia, diabetic ketoacidosis, hypotension (low blood pressure), and thrombocytopenia (low blood thrombocytes, help with clotting). According to the American Diabetes Association, edited 3/18/15, indicated that DKA is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. http://www.diabetes.org/living-withdiabetes/complications/ketoacidosis-dka.html A review of the facility's policy and procedure with revised date of 4/07, titled, "Admission Assessment and Follow Up: Role of the Nurse," indicated the facility was to gather information about the resident's physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 8 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055247 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY OAKS CARE CENTER 215 W Pearl St Pomona, CA 91768 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE condition upon admission and initiate a care plan. The nurse was to conduct an admission assessment (history and physical), including: A summary of the resident's medical history that included: hospitalizations, acute illnesses, relevant medical, social, and family history. This policy and procedure was also used for resident readmissions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I3NE11 Facility ID: CA950000040 If continuation sheet 9 of 9