COLVILLE, WA - Federal inspectors found serious medication monitoring failures at Prestige Care & Rehabilitation - Pinewood Terrace that put diabetic residents at risk when staff failed to properly notify healthcare providers of dangerous blood sugar and blood pressure levels.
Critical Blood Sugar Emergency Goes Unreported
The most serious incident involved a diabetic resident whose blood sugar dropped to a dangerous 46 mg/dl on May 6, 2025. Normal blood sugar levels typically range from 70-140 mg/dl, making this reading potentially life-threatening. The resident required two doses of emergency glucose gel and became lethargic, moaning and stating "I do not want to die."
The resident also developed low oxygen levels at 86% while receiving supplemental oxygen, requiring an increase from 2 to 3 liters. Normal oxygen saturation should be 95-100%. Despite these critical symptoms, nursing staff failed to notify the healthcare provider as required by facility policy and physician orders.
When blood sugar drops below 70 mg/dl, the brain begins to lose its primary fuel source. At 46 mg/dl, residents face risks of confusion, loss of consciousness, seizures, and potentially fatal complications. The facility's own hypoglycemic protocol required provider notification if blood sugar remained below 70 mg/dl after two glucose treatments.
Medication Documentation Failures
Records showed additional concerning gaps in care documentation. The nursing staff failed to document the glucose gel administration on the medication record, despite giving two doses. This creates dangerous gaps in the resident's medical history that could affect future care decisions.
Later that same day, the resident refused medications, developed viral gastroenteritis with poor oral intake, and continued requiring extra oxygen support. Staff documented that oxygen levels dropped when the resident talked, yet there was no record of provider notification despite the resident's deteriorating condition.
Blood Pressure Monitoring Lapses
A second resident with stroke history and hypertension experienced critically low blood pressure readings over multiple days in May 2025. Blood pressures of 88/60, recorded on three consecutive days, fell well below normal ranges of 120/80 or the resident's typical readings.
Low blood pressure, particularly in stroke patients, can reduce blood flow to the brain and other vital organs. The facility appropriately held blood pressure medications when readings dropped, but failed the critical step of notifying the healthcare provider about the significant change.
The resident was receiving alert charting for gastroenteritis during this period, which can cause dehydration and contribute to low blood pressure. Staff were specifically instructed to monitor and document vital signs and adverse effects, yet no progress notes addressed the abnormal readings.
High Blood Sugar Incidents Ignored
A third resident experienced multiple episodes of dangerously high blood sugar levels exceeding 300 mg/dl throughout April and May 2025. Blood glucose readings of 401 mg/dl occurred twice in one day, with additional readings of 315 and 322 mg/dl on other dates.
Prolonged high blood sugar levels above 300 mg/dl can lead to diabetic ketoacidosis, a potentially fatal condition where the body begins breaking down fat for energy, producing toxic acids. The condition requires immediate medical intervention to prevent coma or death.
Facility orders specifically required staff to notify the provider for blood sugar levels greater than 300 mg/dl. Despite multiple violations of this threshold, medical records showed no documentation of provider notifications or additional treatment orders.
Missing Blood Sugar Checks
The inspection also revealed instances where required blood sugar monitoring was simply not performed. Records showed missing bedtime blood sugar checks with no documentation explaining why the monitoring was skipped or delayed.
For diabetic residents, consistent blood sugar monitoring provides essential data for medication adjustments and early detection of dangerous trends. Missed readings can result in inappropriate insulin dosing and delayed recognition of complications.
Staff Acknowledgment of Failures
When interviewed by inspectors, the Licensed Practical Nurse who cared for the residents acknowledged the failures. "Any vital signs that were out of the normal range was to be reported to the provider and this was not done and should have been," the nurse stated.
The nurse also confirmed they did not remember notifying providers about the low blood pressures and acknowledged failing to document the glucose gel administration. They recognized that low blood pressures in an ill resident could indicate dehydration requiring emergency room evaluation.
The facility's Nurse Practitioner emphasized that abnormal vital signs in sick residents could signal dehydration or need for emergency care, stating they would want notification of low blood sugars and low blood pressures.
Policy Requirements Ignored
Facility policies clearly outlined requirements for provider notification during significant condition changes. The November 2017 change of condition policy required immediate communication with healthcare providers for life-threatening conditions or marked changes in status.
The policy specifically required documentation of resident assessments, care provided, physician responses, orders, and resident status. These documentation requirements serve both patient safety and legal protection purposes, ensuring continuity of care and clear communication among healthcare team members.
Medical Protocol Standards
Standard diabetes care protocols require immediate intervention for blood sugar levels below 70 mg/dl or above 300 mg/dl. These thresholds exist because both conditions can rapidly become life-threatening without proper medical management.
Healthcare providers need real-time information about these incidents to adjust medication regimens, order additional monitoring, or recommend emergency evaluation. Delays in communication can result in continued dangerous episodes or missed opportunities for preventive interventions.
Regulatory Compliance Issues
The violations represent failures in basic nursing home care standards under federal regulations requiring appropriate treatment according to physician orders and resident care plans. These standards exist to ensure residents receive timely, appropriate medical intervention when their conditions change.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, but noted they affected multiple residents and represented systemic failures in communication protocols rather than isolated incidents.
The inspection findings highlight the critical importance of proper medication monitoring, documentation, and provider communication in nursing home settings where residents depend on staff for life-sustaining care management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prestige Care & Rehabilitation - Pinewood Terrace from 2025-05-23 including all violations, facility responses, and corrective action plans.
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