Victoria Post Acute Care

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to check a resident's blood sugar for a resident with diabetes (high blood sugar) for one of two sampled residents reviewed for diabetes management (Resident 1).

This failure had the potential to place Resident 1 at risk for poor diabetes management.Findings: On 8/21/25, the Department received a complaint related to Resident 1's untimely and missed blood sugar check at the facility. Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes and on long term use of insulin (injectable medication for diabetes), per the facility's admission Record. Resident 1's history and physical, dated 7/29/25 indicated Resident 1 had the capacity to understand and competent to make complex medical decisions. On 9/4/25 at 1:13 P.M., a joint interview with the Director of Nursing (DON) and a review of Resident 1's clinical record was conducted.

The DON stated Resident 1 was alert and oriented and knew what was going on.

The DON stated Resident 1's blood sugar was checked four times a day (before meals and at bedtime).

The DON stated on 7/30/25, Resident 1's blood sugar was documented as checked at 9:52 A.M.

The DON stated the facility usually served breakfast around 8 A.M.

The DON also stated on 7/30/25, there was no blood sugar check documented for Resident 1 before lunch.

The DON stated Licensed Nurse (LN) 2 was the LN who worked that day.

The DON stated there was no blood sugar check and no insulin coverage at lunch time for Resident 1.

The DON stated there was no documentation Resident 1 refused blood sugar check.

The DON stated the expectation was for the LNs to follow the physician's order and document in the resident's clinical record.

The DON stated blood sugar monitoring was important so the facility could implement appropriate interventions if high or low. On 9/4/25 at 1:39 P.M., a telephone call was made to interview LN 2, but unable to talk to LN 2. A policy for diabetes management was requested but per DON, the facility had a policy for Physician Orders. A review of the facility's undated policy titled, Physician Orders - Administration of Medications/Treatments, indicated, It is the policy of this Facility, medication and treatment shall be administered by Licensed Nurse as prescribed by the resident's physician .4.

Medication and treatment administration will be recorded on the resident's administration record (i.e. MAR/TAR/DAR).

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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