complaint·August 13, 2024

Regarding the allegations: 1.) Facility staff admitted a resident beyond their level of care. 2.) Facility staff not ensuring resident's diabetic needs are met. On 07/23/2024, the Department received a complaint alleging that Resident #1 (R1) who is diabetic and requires finger prick testing twice a day to test blood sugar was admitted to the facility. The complainant is alleging that R1 does not have the capacity to perform a self-finger prick test and the facility does not have an appropriate skilled professional to perform the test, hence not meeting R1’s diabetic needs. Per record review, R1 was discharged from Kaiser Permanente Hospital and admitted to the facility on 06/08/2024. Per R1’s hospital records and discharge medication list dated 06/08/2024, R1 was to continue performing OneTouch Verio test strips with the following instructions “Check your blood sugar 2 times a day every morning before breakfast and every evening before dinner.” Per R1’s physician report dated 06/07/2024, R1’s primary diagnosis is noted as Dementia and secondary diagnosis as Diabetes. R1’s physician report also indicated that R1 is not “Able to perform own glucose testing.” During R1’s stay at the facility, R1’s blood sugar was not being tested daily. On 07/23/2024, the previous management team quit and did not leave clear instructions regarding R1’s diabetic needs to remaining staff. Interviews with staff revealed that R1 was not getting their blood sugar tested and instead, previous management was attempting to contact R1’s physician to get the blood sugar test discontinued. Additionally, the facility does not have a skilled professional to perform R1’s blood sugar test. The facility’s current ED, Trevin Willis, worked with R1’s family to find an appropriate licensed facility that can perform R1’s blood sugar test. On 08/08/2024, R1 was moved out of the facility. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations of “Facility staff admitted a resident beyond their level of care” and “Facility staff not ensuring resident's diabetic needs are met” are deemed Substantiated . Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.