Clinical Consultant (PCC) conducted a medical record review for R1, which was completed on 09/22/2022. The following was then determined:

Regarding the allegation “Staff did not report a change in condition to resident’s authorized representative:”

Record review revealed that R1 moved into the facility on 02/28/2020. R1’s physician’s report dated 02/21/2020 indicated R1’s diagnoses included hyperlipidemia, diabetes type 2, major depressive disorder, and atherosclerotic heart disease. R1’s weight as indicated on the physician’s report was 189 pounds and height was 72”. R1’s care plan dated 02/16/2020 indicates diabetic alerts, fall risk, vitals/weights monthly – every 1^st Wednesday. Interview and record review revealed that there was no weight check conducted on the 1^st Wednesday in March 2020 or April 2020. R1’s weight record indicates on 5/1/2020 R1 weighed 165 pounds, indicating a 24 pound weight loss in 2 ½ months. Interview revealed that the facility’s computerized weight management system will automatically alert staff of significant weight loss. However, since no weights were recorded in March or April, facility Designee stated that the computer system did not alert staff of the weight loss. R1’s weight was measured on 06/25/2020 the hospital and recorded at 153 pounds, indicating an additional 12 pound weight loss since 05/01/2020. Interview with R1’s family members revealed that they were not made aware of R1’s weight loss, nor that R1 was not eating. Additionally, care notes reviewed did indicate “all parties were notified” of the falls R1 sustained on 06/15/2020, 06/18/2020, 06/21/2020, and 06/22/2020. However, record review revealed that R1’s Primary Care Physician (PCP) was only notified of the last two of the four fall incidents. Facility staff did not complete a new care plan for R1 due to the increased number of falls or significant weight loss. Based on interview and record review, the allegation that “staff did not report a change in condition to resident’s authorized representative” is deemed SUBSTANTIATED at this time.

Regarding the allegation “Staff did not seek medical attention for resident in a timely manner:”

Medication Administration Record (MAR) review revealed R1’s physician had ordered a daily blood glucose check. There is no evidence to indicate the facility faxed the monthly blood glucose check, per the PCP’s orders nor is there evidence to prove the facility informed the PCP about the resident’s low blood sugar levels on 03/25/2020 or on the 7 dates in June 2020 in which R1 was experiencing low blood sugar (06/07/2020, 06/10/2020, 06/12/2020, 06/14/2020, 06/20/2020, 06/21/2020, and 06/22/2020.) Documents Report Continued on LIC 9099-C

reviewed revealed the only time the blood glucose check was faxed was on 06/23/2020, once R1 had already been transported to the hospital. Records reviewed revealed that R1’s PCP responded promptly with a change in medication based on the reports received on 06/23/2020. Additionally, as previously identified above, R1’s physician was not made aware of 2 of 4 occurrences in which R1 fell in June 2020. R1 also lost a total of 36 pounds (or 19% of R1’s total body mass), during the time R1 resided at the facility, between 02/21/2020 and 06/25/2020. Interview revealed facility staff were unaware of R1’s weight loss, and therefore had not reported to the resident’s physician. Care notes revealed R1 had informed staff they were not eating, but this was also not reported to a medical professional until R1 reported to hospital staff during the 06/23/2020 hospital intake. Therefore, based on interview and record review, the allegation “staff did not seek medical attention for resident in a timely manner” is deemed SUBSTANTIATED at this time.

Regarding the allegation “staff mismanaged Resident’s medication:”

Medication Administration Record (MAR) review revealed R1’s physician had ordered a daily blood glucose check. MAR indicates “please fax monthly report to Dr.” A review of PCP records revealed there was no evidence to indicate the facility followed the doctor’s orders to fax the monthly report of the daily blood sugar level for the resident. There was also no evidence to indicate the facility informed the PCP about the resident’s low blood sugar levels on 03/25/2020 or on the 7 dates in June 2020 in which R1 was experiencing low blood sugar. Documents reviewed revealed the only time the blood glucose check was faxed was on 06/23/2020, once R1 had already been transported to the hospital. Additionally, although R1’s prescription medication Glimerpiride was ordered “take with breakfast” and Metformin was to be taken “twice a day *take with food” although facility staff documented in care notes R1 was not eating, medications were still administered daily without food. Progress notes indicate R1 did not have breakfast, lunch or dinner on 06/22/2020 and was hypoglycemic on this date. However, both medications ordered to be given with food were still administered. Blood glucose check performed by the facility Licensed Vocational Nurse (LVN) on 06/23/2020 at 07:00AM, indicated his blood glucose level was 23. Progress note indicated R1 was then given ½ cup of orange juice at 07:36AM. Another blood glucose check was performed at 08:16AM and measured even lower at 21. An additional ½ cup of orange juice was given to R1. As per niddk.nih.gov, orange juice is not to be given when one is having hypoglycemia for people with kidney disease, due to its high potassium content. Medication Administration Record (MAR) reviewed indicated both glimepiride and Report Continued on LIC 9099-C

metformin (both medications are listed on www.ncbi.nlm.nih.gov as used to lower blood glucose levels) scheduled at 09:00AM were given to R1 during a period of hypoglycemia prior to Emergency Medical intervention. Therefore, based on interview and record review, the allegation “staff mismanaged Resident’s medication” is deemed SUBSTANTIATED at this time.

Regarding the allegation “staff did not ensure resident needs were met:”

The allegation refers to R1 allegedly not eating or drinking while residing at the facility. R1 moved into the facility on 02/28/2020. R1 chose a vegan diet and interview revealed staff were aware of the resident’s chosen dietary needs. Progress notes indicate “late entry for 02/28/2020 5:00PM…(R1) is diabetic and vegan.” Interview with R1’s family members revealed prior to move in, facility staff assured R1 that the facility was able to accommodate R1’s dietary preferences. LPA Dulek reviewed 5 (five) weekly menus for June-July 2020 as well as the daily order choices. No items listed on the menu were noted as vegan, therefore, without viewing recipes, it is difficult to discern whether the printed menu contains any vegan options. As far as listed entrees, 0 (zero) of 35 (thirty five) lunch menu entrée choices and 0 (zero) out of 70 (seventy) dinner menu entrée choices appeared to be vegan. Approximately 2 (two) times a week, the soup offered at lunch was likely vegan as well as many salads, side dishes, and desserts would likely fit within R1’s vegan diet. However, R1 was also diabetic, and according to www.niddk.nih.gov, “the key to eating with diabetes is to eat a variety of healthy foods from all food groups.” No protein options listed on the facility menu were vegan. Additionally, the time period R1 resided in the facility was during COVID “safer at home orders” and residents were isolated in their rooms. Meals were delivered to resident rooms, and residents were asked to order according to the menu choices. Interview revealed that R1 was only ordering side dishes and desserts. Care notes revealed that R1 did not eat at all on 06/22/2020. R1 had a total weight loss of 36 pounds within a 4-month time frame while residing at the facility, which could also indicate R1 was not receiving proper nutrition. Review of medical documentation revealed R1’s weight loss nor decreased oral consumption was reported to R1’s PCP and interview revealed it was not reported to R1’s family members either. Therefore, based on interview and record review, the allegation “staff did not ensure resident needs were met” is deemed SUBSTANTIATED at this time.

Report Continued on LIC 9099-C

Regarding the allegation “Resident fell multiple times in care:”

Upon admission to the facility, R1’s physician’s report indicated good physical health status for R1. R1 was listed as non-ambulatory, but able to independently transfer to and from bed. Service Agreement dated 02/16/2020 indicates service type: Alerts: Fall Risk, Mobility: 1 person wheelchair, Transfers: Assist, Night Care: once each shift. Progress notes indicate R1 fell on 06/15/2020 around 02:00PM. Interview revealed that R1’s responsible party was notified that R1 would be on increased status checks to monitor R1’s safety post-fall. Subsequently, R1 fell again on 06/18/2020, which was noted in the progress notes at 03:23PM. Facility staff indicated they would extend the 3-day monitoring an additional 3 days to ensure resident safety. Again, on the 3^rd day (06/21/2020,) R1 fell a third time over a 6-day period. Interview revealed R1’s family member called R1 just after R1 had fallen on 06/21/2020, so R1 informed them of the fall, but the facility did not. R1 fell a 4^th time on 06/22/2020, which was documented in Progress Notes at 08:26PM. Documentation reviewed revealed R1’s physician was only informed of the last 2 of the 4 total falls. Facility staff was aware that R1 was a fall risk upon admission to the facility. Then the facility did not modify R1’s care plan although R1 was noted falling frequently. The facility was unable to provide any documentation reflecting increased status checks or increased monitoring following the first three falls. It wasn’t until 06/21/2020 that Progress Notes indicate “requested orders for PT/OT for right arm and gait,” but still no change in condition or change in level of care was indicated at that time. Therefore, based on interview and record review, the allegation that “resident fell multiple times in care” is deemed SUBSTANTIATED at this time.

Pursuant to the California Code of Regulations, Title 22, the following deficiencies are cited (please see LIC 9099-D), and an immediate $500 civil penalty was assessed during today’s visit on 10/26/2022. The Executive Director was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f).