complaint·February 13, 2026

Staff Not Meeting Resident’s Medical Needs Based on interviews with staff and review of facility records, it was determined that the facility did not have a documented diabetes care plan for Resident 1 (R1). Records indicate R1 has multiple medical diagnoses of diabetes. The Admission Agreement signed on 04/25/2025 listed a monthly charge for “diabetic management.” However, when requested, facility staff were unable to produce a diabetes care plan outlining how R1’s diabetic needs were monitored or managed. Staff member S3 stated that R1’s blood sugar is checked daily; however, no blood glucose monitoring logs or documentation were available for review to support this statement. The LPA observed that R1’s diabetes was not addressed in the Appraisal/Needs and Services Plan on file. Additionally, the Physician’s Report (LIC 602) dated 04/18/2025 indicated that R1 requires a specialized diet. When requested, the facility was unable to provide a diabetic or specialized menu specific to R1. Staff Not Meeting Resident’s Prescribed Dietary Needs Based on record review and staff interviews, it was determined that the facility did not ensure R1’s prescribed dietary needs were met. The Physician’s Report (LIC 602) dated 04/18/2025 documented that R1 is diagnosed diabetes required a specialized diet and assistance with medical needs. The Admission Agreement signed on 04/25/2025 identified Diabetic Management under other personal care needs. Despite this, when the LPA requested documentation of a diabetic diet or diabetes care plan, staff member S1 stated that no such plan existed. Staff member S3 reported that blood glucose monitoring was conducted using a glucose monitor; however, no logs or records were available to verify ongoing monitoring. Additionally, the facility was unable to provide a sample menu or documentation demonstrating that R1 was receiving meals consistent with a prescribed diabetic or modified diet. Deficiencies cited on LIC9099-D Exit interview conducted. Copy of report was provided to licensee.