Resident 53, who has Type 2 diabetes and end-stage renal disease, had been receiving insulin injections according to a sliding scale before being transferred to Greater Anaheim Community Hospital on an unspecified date. Medical records show the resident received insulin doses ranging from 2 to 3 units based on blood sugar levels from October 26 through November 27, 2024.
The resident's blood sugar readings during that period ranged from 152 mg/dL to 234 mg/dL, with insulin administered when levels exceeded 150 mg/dL according to the prescribed sliding scale.
When Resident 53 returned from the hospital on December 8, 2024, no insulin orders were in place. The facility's Order Summary Report dated January 12, 2025 — more than a month later — still showed no medications or treatment orders for the resident's diabetes.
"If there are no orders for diabetic management, the resident can experience hyperglycemia and have uncontrolled blood sugar," the Director of Nursing told inspectors during a January 12 interview.
The resident's diabetes care plan remained active throughout this period. The plan, initiated October 26, 2024 and revised November 6, called for administering medications as ordered, monitoring blood sugar levels, and notifying the physician if blood sugar dropped below 60 or rose above 400 mg/dL.
Federal inspectors found the oversight during their January 12 visit when reviewing the resident's medical records. The Director of Nursing acknowledged that no physician orders existed for diabetic management and said she would have clarified orders with the attending physician upon readmission.
"When verifying the orders as the admitting nurse, she would have clarified with Physician 1," inspectors noted. The Director of Nursing said she expected nurses to question and clarify with the physician as well.
The facility's Consultant Dietitian compounded the confusion by incorrectly ordering a diabetic diet for the resident. During her January 12 interview, the dietitian admitted she "must have missed resident's diagnosis of Diabetes Mellitus when completing the Nutritional Initial Screener."
She had ordered a consistent carbohydrate diet designed for people with diabetes to manage blood sugar levels, despite later stating "there was no diagnosis of diabetes" and that "the resident's blood sugar at the time was normal." The dietitian could not recall what the resident's blood sugar level was during her assessment.
The resident's actual diet orders called for an 80-gram renal diet with low potassium and low salt, appropriate for someone with end-stage renal disease requiring dialysis. The dietitian explained that the dialysis diet took precedence over a diabetic diet.
Resident 53's medical history shows a complex case requiring careful medication management. Records indicate the resident was initially admitted with acute pulmonary edema, Type 2 diabetes, and end-stage renal disease. A December 16 assessment found the resident had the capacity to understand and make decisions.
The missing insulin orders represented a significant gap in care for someone whose medical records documented regular insulin use. The resident had received insulin injections on 22 separate occasions between October 26 and November 27, with blood sugar levels consistently requiring intervention according to the prescribed sliding scale.
On November 20, the resident received 3 units of insulin for a blood sugar reading of 234 mg/dL. Three days later, another 2 units were administered for a reading of 209 mg/dL. These were among the final recorded insulin doses before the hospital transfer.
The facility's policy requires the multidisciplinary team to conduct nutritional assessments that identify current clinical conditions and risk factors that may affect a resident's nutritional status. The policy calls for assessments upon admission and when conditions change that place residents at risk for impaired nutrition.
Federal inspectors also found the facility failed to provide appropriate oxygen therapy to another resident. Resident 15, who has chronic respiratory failure and requires continuous oxygen, was receiving 4.5 liters per minute when the physician order specified 2 to 4 liters per minute.
A Licensed Vocational Nurse observed the oxygen machine set at 4.5 liters during an evening shift January 10. "The resident can get hyperoxygenation if the oxygen is not at the right dose," the nurse told inspectors.
The Director of Nursing confirmed the importance of correct oxygen dosing. "The residents can get hyperoxygenation if they are given too much oxygen. They can get seizures and possibly get injured as a result," she said.
Additional violations included a consultant pharmacist's recommendation that went unaddressed for three months. The pharmacist recommended in October that Resident 18 receive blood work to monitor basic metabolic panel levels, but the facility never communicated this recommendation to the attending physician.
In the kitchen, inspectors found an open package of ground beef in the freezer without a date marking when it was opened. The Dietary Director acknowledged the violation: "We don't know how long something has been opened if there is no opening date. This pack of ground beef does not have an opening date on it. It might be old and cause a resident to get sick if they eat it."
The facility's infection control practices also drew scrutiny when a Licensed Vocational Nurse administered medications to a resident requiring enhanced barrier precautions. The nurse initially was unaware when to wear protective equipment and later disposed of contaminated materials in a hallway bin instead of inside the resident's room.
Outside the building, inspectors documented trash scattered across the facility's parking lot within view of resident room windows. Broken containers, wooden pallets, and other debris littered the ground near an overflowing dumpster.
"It is not a homelike environment to see trash outside the window or to have trash scattered in the facility's parking lot," the Director of Nursing told inspectors. "It may make me feel like the facility is dirty if I was a resident and saw that."
For Resident 53, the month without insulin orders meant living with uncontrolled diabetes while recovering from acute pulmonary edema and managing end-stage renal disease requiring dialysis. The resident's capacity to make medical decisions made the oversight particularly concerning, as someone aware enough to understand their medical needs was left without essential diabetes management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Socal Post-acute Care from 2025-01-12 including all violations, facility responses, and corrective action plans.