Health inspection·March 26, 2025

F684 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:

F635 42 CFR §483.20(a) Admission orders At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care. 22 CCR § 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. (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. 22 CCR § 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (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. 22 CCR § 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. An unannounced visit was conducted by California Department of Public Health on 2/21/2025 to investigate a complaint regarding an allegation that a resident sustained a critical decline in health and hospitalization due to a facility nurse not following the resident’s medication order upon admission on 12/17/2024. 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 level because the body does not produce insulin (a hormone made by the pancreas-an organ in the body)] received treatment and services, in accordance with professional standards of practice (guidelines and principles that define expected conduct, skills and responsibilities of professional in their roles) by failing to: 1. Ensure a licensed staff reviewed Resident 1’s medical history of DM and complete the medication reconciliation (a formal process that involves healthcare providers and patients to ensure accurate medication information is communicated during care transition) of discharge orders from General Acute Care Hospital (GACH) 1 for Resident 1’s insulin lispro (medication used to treat diabetes), insulin glargine (medication used to treat diabetes), and blood sugar monitoring upon the resident’s admission at the facility on 12/17/20224. 2. Verify with Resident 1’s admitting physician (MD 1) if blood sugar monitoring and/or insulin lispro and/ or insulin glargine order from GACH 1 should be continued while Resident 1 is residing at the facility from 12/17/2024 to 12/21/2024. As a result, Resident 1 had a change in condition on 12/21/2024, manifested by altered level of consciousness (ALOC- a state of being less awake or alert than normal). Resident 1 was transferred to the GACH 2 via 911 (emergency contact number) emergency services. Resident 1’s presented at GACH 2’s Emergency Department (ED) unresponsive and with blood sugar level of 1400 milligrams per deciliter (mg/dL- unit of measurement. Normal value for an adult with DM is 80 to 130 mg/dL before meals and less than 180 mg/dL two hours after meal) on 12/21/2024 and was diagnosed with diabetic ketoacidosis (DKA- a serious complication of diabetes that occurs when the body does not have enough insulin) in GACH 2. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1 is a 60-year-old-male, was admitted to the facility on 12/17/2024, with diagnoses including, type 1 diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]) without complications, hypertension (high blood pressure), and sepsis (infection of the blood). A review of Resident 1's History and Physical (H&P – a formal assessment of a patient and their medical condition performed by a healthcare provider, usually during an initial visit) dated 12/17/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS- resident assessment tool), dated 12/21/2024, indicated Resident 1 had impaired cognitive skills (mental action or process of acquiring knowledge and understanding) in decision making. The MDS also indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) from staff for eating, toileting hygiene, and personal hygiene. A review of Resident 1’s GACH 1 Patient Discharge Instructions and Plan (PDIP) dated 12/17/2024, included the following prescribed orders: 1. Insulin glargine 50 units (a unit of measure of volume) subcutaneous (SC-delivers medication into the fatty tissue beneath the skin) once a day (in the morning), 2. Insulin lispro 1 unit SC with breakfast, 3. Insulin lispro 1 unit SC with lunch, 4. Insulin lispro 1 unit SC with dinner, 5. Routine blood glucose testing (measures blood sugar levels, crucial for diagnosing and managing diabetes). A review of Resident 1’s Progress Noted dated 12/21/2024 and timed at 11:15 PM, documented by LVN 1, indicated Resident 1 was observed having ALOC and non-responsive. A review of Resident 1’s GACH 2’s History and Physical (H&P) and Discharge Summary, dated 12/22/2024, it indicated the resident was admitted at GACH 2 on 12/22/2024 at 12:14 AM. The H&P indicated, upon arrival to the emergency department, Resident 1’s blood sugar level was 1400s mg/dL and the resident was unresponsive. The discharge summary indicated resident was diagnosed with DKA. During a concurrent interview and record review with Quality Assurance Nurse (QAN) on 2/21/2024 at 11:45 AM, Resident 1's Medication Administration Record (MAR) dated December 2024 and Resident 1’s GACH 1 PDIP dated 12/17/2024 were reviewed. The MAR did not indicate an order for insulin glargine, insulin lispro and routine blood glucose testing. QAN stated, “It was noted that the MAR for December 2024, was not updated reflecting the orders that were indicated in GACH ‘s Patient Discharge Instructions and Plan regarding insulin medications (glargine and lispro) and routine testing blood glucose”. QAN stated medication reconciliation should be completed upon the resident’s admission, and the license nurse reviews the discharge orders/ instructions from GACH, then informs and verify with the resident’s admitting doctor if need to add/ continue the orders in the facility for continuity of care. During concurrent interview and record review with the Assistant of Director of Nursing (ADON) on 2/21/2025 at 2:34 PM, Resident 1's Order Summary Report dated 12/1/2024 to 12/31/2024 was reviewed. The order summary report did not indicate an order for Resident 1’s blood glucose monitoring, insulin glargine and insulin lispro. ADON stated Resident 1’s Order Summary Report did not indicate that Resident 1 had orders to monitor the resident’s blood sugar, and to administer insulin glargine and/ or insulin lispro from 12/17/2024 to 12/21/2024. ADON stated it was important review the residents PDIP to complete the medication reconciliation when a resident is admitted from GACH to ensure continuity of care while residing in the facility. During the same interview and record review with ADON on 2/21/2025 at 2:34 PM, the facility’s policy and procedure, titled “Admission Assessment” dated 8/30/2019 was reviewed. The policy indicated, the licensed nurse will complete a drug regimen review (comprehensive evaluation of a patient's medication list to identify and address potential problems, optimize therapy, and ensure safe and effective drug use) upon admission or as close to the actual time of admission as possible to identify any potential or actual clinically significant medication issues. The policy also indicated the licensed nurse will contact the physician to communicate any identified medication issues and compile all physician prescribed/recommended actions by midnight of the next calendar day. ADON stated, the policy indicated drug regimen review meaning the medication reconciliation should have been completed for Resident 1 when the resident was admitted at the facility on 12/17/2024 from GACH 1. During a concurrent interview and record review with LVN 1 on 2/21/2025 at 3:02 PM, Resident 1’s Change in Condition (COC) dated 12/21/2024 was reviewed. The COC indicated at 11:15 PM, Resident 1’s Vital Sign (VS-clinical measurements of person’s essential body functions) was 90/40 [Blood pressure-BP and Oxygen Saturation [amount of oxygen in the blood] of 86 % [normal levels between 95 to 100%]. LVN1 confirmed Resident 1’s blood sugar level was not checked at the time of the resident’s COC. LVN 1 stated Resident 1 had a known history of diabetes and blood sugar level should have been tested to identify whether the resident was hypoglycemic [low blood sugar level] or hyperglycemic [high blood sugar levels] for appropriate treatment. During an interview with Administrator (ADM) on 2/21/2025 at 3:11 PM, ADM stated medication reconciliation was important to ensure that residents received the right medications, in the right dose, and at the right time. During a telephone interview with Registered Nurse 1 (RN 1) on 3/4/2025 at 11:25 PM, RN 1 stated the process of admitting a new patient is the following: The admission team review and reconcile the resident’s medications, then notifies primary doctor (admitting doctor) to obtain new order or keep the GACH’s discharge medication order, then the facility transcribes the order to resident’s Order Summary and MAR. RN 1 stated once the process completed, the charge nurse initiates and carries out (implement) the order, however, it was not done for Resident 1. During a telephone interview with RN 2 on 3/5/2025 at 9:40 AM, RN 2 stated Resident 1 was admitted to the facility without resident’s GACH 1 PDIP medication orders being reconciled which resulted in Resident 1 not receiving the appropriate admission orders for DM care such as monitoring of blood glucose level, administering insulin lispro and/ or insulin glargine, and could have the cause of Resident’s 1’s COC on 12/21/2025. The facility failed to ensure Resident 1 who had a diagnosis of DM received treatment and services, in accordance with professional standards of practice by failing to: 1. Ensure a licensed staff reviewed Resident 1’s medical history of DM and complete the medication reconciliation of discharge orders from GACH 1 for Resident 1’s insulin lispro, insulin glargine, and blood sugar monitoring upon admission on 12/17/20224. 2. Verify with MD 1 if blood sugar monitoring and/or insulin lispro and/ or insulin glargine order from GACH 1 should be continued while Resident 1 is residing at the facility from 12/17/2024 to 12/21/2024. As a result, Resident 1 had a change in condition on 12/21/2024, manifested by altered level of consciousness, and was transferred to the GACH 2 via 911 emergency services. Resident 1’s presented at GACH 2’s emergency department unresponsive and with blood sugar level of 1400 mg/dL on 12/21/2024 and was diagnosed with DKA in GACH 2. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.