Health inspection·September 26, 2025

F656 §483.21(b) Comprehensive Care Plans §483.21(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 — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (iv) In consultation with the resident and the resident’s representative(s)— (A) The resident’s goals for admission and desired outcomes.

F684 § 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.

F756 §483.45(c) Drug Regimen Review. §483.45(c)(2) This review must include a review of the resident’s medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility’s medical director and director of nursing, and these reports must be acted upon. On 8/13/20205, at 11:15 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate two complaints regarding the quality of care of a resident (Resident 1). As a result of the investigation, CDPH determined that the facility failed to provide the necessary diabetic care and services to Resident 1 who had a diagnosis of type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) by failing to ensure: 1. The licensed nurses coordinated with the physician in management of Resident 1 DM that included checking blood sugar level and administering medication for DM since readmitted to the facility on 7/14/2025 to 8/9/2025 (total 9 days) in accordance with Physician 1’s H&P treatment plan. 2. To implement a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) developed on 7/15/2025 with interventions on how to manage DM for Resident 1 in accordance with the facility’s care plan policy. 3. The Pharmacy consultant performed a comprehensive Medication Regimen Review (MRR, medication regimen reviews a thorough evaluation of the medication regimen of a resident, to promote positive outcomes and minimizing adverse consequences and potential risks associated with medication) by reviewing Resident 1’s clinical records in accordance with the facility’s P&P. These deficient practices resulted in Resident 1’s experiencing hyperglycemia (a condition where there's too much glucose in the blood) and placed the resident at risk for serious complications, in ketoacidosis (DKA, a complication of diabetes in which acids build up in the blood to levels that can be life-threatening), dehydration (a condition occurs when the body loses more fluids than it takes in, leading to an insufficient amount of water for normal bodily functions), confusion (a state of reduced awareness and impaired thinking) and coma (a state of prolonged unconsciousness where a person is alive but unresponsive to their surroundings). A review of Resident 1’s General Acute Care Hospital (GACH) 1’s Laboratory test result (prior to admission to the facility), dated 7/10/2025, indicated Resident 1’s hemoglobin A1C (HA1C, a blood test that reflects average blood sugar levels over the past two to three months) was 7.1% indicating higher than the normal range (normal range below 5.7%) A review of Resident 1’s GACH 1’s Nursing Narrative Note, dated 7/10/2025, indicated the nurse notified Physician 1 the result of HA1C lab result of 7.1% and Physician 1 ordered to administer Metformin (a medication used to treat Type 2 DM) 500 milligrams (MG, a unit of measurement) twice a day to Resident 1. A review of Resident 1’s GACH 1’s Orders, dated 7/10/2025, indicated Physician 1 ordered Metformin 500 MG one table orally (by mouth) twice per day before meals on 7/10/2025. A review of Resident 1’s GACH 1’s Medication Tasks-Scheduled (MT), dated 7/11/2025 to 7/14/2025, indicated Resident 1 received Metformin 500 MG one table orally twice per day before meals from 7/11/2025 and 7/14/2025. A review of Resident 1’s Admission Record (AR), indicated a 75-year-old male resident was admitted to the facility on 7/14/2025, with diagnosis of type 2 diabetes with hyperglycemia (high blood sugar). A review of Resident 1’s care plan titled, “The resident has diabetes mellitus,” initiated on 7/15/2025, the care plan goals included for the resident to be free from signs and symptoms of hyperglycemia and hypoglycemia (low blood sugar) and free of complications related to diabetes. The care plan’s interventions included the following: 1. Diabetes medications as ordered by doctor. 2. Monitor/document/report to the physician as needed for any signs and symptoms of hyperglycemia. 3. Monitor/document/report to the physician as needed for any signs and symptoms of hypoglycemia. A review of Resident 1’s H&P, dated 7/15/2025, indicated Physician 1’s plan was for “Accu-check” (checking blood sugar level with the use of a machine, by pricking the finger and collecting a small blood sample on a test strip, which would be read by the machine) daily, continue DM meds.” A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 7/18/2025, indicated Resident 1 had severely impaired cognitive (ability to think and reason) skills for daily decision making was moderately impaired memory and cognition (ability to think and reasonably) that was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing and putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 had no orders of insulin and not taking a hypoglycemic (medications that decrease blood sugar). A review of Resident 1’s Medication Administration Record (MAR), from July 2025-August 2025, indicated Resident ‘s blood sugar level was not checked via Accu-check, and did not receive any medication to control blood sugar level from 7/14/2025 to 8/8/2025. A review of Resident 1’s Situation, Background, Appearance, Review and Notify Communication Form (SBAR, a form to communicate about a resident’s change of condition), dated 7/22/2025 at 2:52 PM, indicated Resident 1 had weight loss of six pounds per week related to decreased edema (swollenness in the body due to fluid retention) and the physician recommended to obtain Complete Blood Count (CBC, a common blood test that analyzes the three main types of blood cells), Comprehensive Metabolic Panel (CMP, a blood test that measures 14 different substances in the blood that includes blood sugar level), lipid panel (a blood test that measures different types of fats in the blood), and Thyroid-Stimulating Hormone (TSH, a blood test to check thyroid [a gland that regulating energy, growth and organ function] function) A review of Resident 1’s laboratory CMP result, obtained 7/23/2025, indicated Resident 1’s blood sugar level was 289 milligram per deciliter (MG/DL, a unit of measurement) which was high according to reference range (70-110 MG/DL). A review of Resident 1’s Consultant Pharmacist’s MRR dated 7/1/2025 - 7/28/2025, indicated the pharmacist recommended to clarify the route for medication Gabapentin (medication to treat epilepsy [a brain disease] and nerve pain). A review of Resident 1’s SBAR, dated 8/9/2025 at 9:50 AM, indicated Resident 1 complained about weakness and not feeling well and with the blood sugar level of sugar was at 557 milligram per deciliter (mg/dl) and the physician ordered regular insulin with sliding scale and metformin. A review of Resident 1’s MAR, dated 8/9/2025 at 11:30 AM, indicated Resident 1’s blood sugar level was 358 mg/dl and Regular Insulin (a fast-acting medication injected under the skin to help lower blood sugar level) was administered to Resident 1 per sliding scale. A review of Resident 1’s Order Summary Report, dated 8/11/2025, indicated the physician ordered for the resident to receive Regular insulin injection subcutaneously (injected under the skin) as per sliding scale, starting on 8/9/2025. During a record review of Resident 1’s clinical records and concurrent interview with RN 3 on 8/13/2025 at 2:25 PM, RN 3 stated according to the MAR Resident 1’s blood sugar was not checked from 7/14/2015 to 8/8/2025. RN 3 stated when she texted a picture of Resident 1’s laboratory results showing blood sugar level of 289 mg/dL to Physician 1 on 7/23/2025, she did not inform Physician 1 that Resident 1’s blood sugar was not checked routinely (daily) via Accu-check and the resident was not receiving medications to manage the blood sugar levels. During an interview and concurrent record review of Resident 1’s clinical records with the Director of Nursing (DON) on 8/13/2025 at 4:15 PM, the DON stated Resident 1’s blood sugar level was 358 mg/dl and Regular insulin was ordered by the physician on 8/9/2025 to administer per sliding scale. The DON stated the physician documented in the H&P that to manage Resident I's DM the plan was to perform “Accu-check” daily and continue DM medications. The DON stated there was no documented evidence that the physician wrote in the physician order to check Resident 1’s blood sugar level routinely via “Accu-check” and did not order medications to control the blood sugar of Resident 1 from 7/14/2025 to 8/9/2025. The DON stated if the nurses reviewed the H&P timely, then, the nurse could have clarified with the physician the plan to manage Resident 1’s DM to prevent the resident from experiencing hyperglycemia. During a concurrent record review on 8/14/2025 AM at 10:45 AM, and interview with MDS Nurse 1 (MDSN 1), indicated Resident 1’s care plan was initiated by MDSN 1 on 7/15/2025. MDSN 1 stated Resident 1 did not have a diabetes medication order or blood sugar monitoring on 7/15/2025. During a concurrent record review and interview on 8/14/2025 at 11:25 AM with Registered Nurse 1 (RN 1), Resident 1’s care plan was reviewed. RN 1 stated Resident 1’s care plan was not implemented because Resident 1 was not monitored for low and high blood sugar and was not reported to the physician that the resident was not receiving medication for DM and there was no order to monitor blood sugar level via “Accu-check” since readmission to the facility on 7/14/2025. During a concurrent record review and interview on 8/14/2025 at 12:26 PM with MDSN 2, Resident 1’s care plan was reviewed. MDSN 2 stated Resident 1’s care plans were not implemented since 7/15/2025 to provide specific care for Resident 1’s diagnosis of diabetes mellitus. During an interview on 8/14/2025 at 12:30 PM, MDSN 2 stated MDS nurses should know that when developing a care plan, they have to review all of the pertinent records like hospital records, active orders, doctor’s H&P notes, and resident’s choices and preferences and to ensure the care plan interventions are implemented to address the resident’s needs. During a concurrent interview and record review on 8/14/2025 at 1:08 PM, MDSN 1 stated Resident 1’s H&P was not reviewed during the IDT meeting on 7/24/2025 to discuss about Resident 1’s medical condition. MDSN 1 stated if the H&P was reviewed, the IDT would have noticed the plan to check Resident 1’s Accu-check daily and administer DM medications which were not in the physician’s orders and the teams could have notified the physician for clarification. During a telephone interview on 8/14/2025 at 2:46 PM, the Consultant Pharmacist (CP) stated Resident 1’s medication was reviewed in July 2025, CP stated diabetes mellitus was not included in the list of diagnosis for Resident 1 but he was aware that Resident 1 was receiving insulin from the previous admission to the facility and he failed to review Resident 1’s hospital records for the laboratory results and blood sugar test result when he conducted the MRR last month. The CP stated he did not review Resident 1’s records and he does not routinely review hospital records, laboratory results, and doctor’s notes if there’s something that he needed to would. During an interview on 8/14/2025 at 4:05 PM, the Physician 1 stated he was made aware by nursing staff that Resident 1’s blood sugar level was 289 mg/dl, on 7/23/2025, (9 days after admitted to the facility) but the nurse did not inform him that Resident 1 was not receiving DM medications. Physician 1 stated if he knew Resident 1 was not on any DM medications, he would have ordered to check Resident 1’s blood sugar routinely and order medications to treat his DM. During an interview on 8/14/2025 at 4:39 PM with the DON, the DON stated the nurses should review Resident 1’s H&P and orders to make sure the physician’s treatment plan and orders were consistent with the resident’s diagnoses, and the nurse should notify the physician if there was discrepancy between the treatment plan and the physician’s orders. The DON stated if the nurses reviewed the H&P, they would have been able to notice the discrepancy and obtain the orders for Accu-check and medications to treat DM earlier. During an interview on 8/14/2025 at 4:41 PM with the DON, the DON stated when the nurse reported Resident 1’s abnormal blood sugar level to the p