Complaint·September 10, 2025

R1’s Physician’s Report dated February 28, 2025, indicated R1 had a secondary diagnosis of Diabetes Mellitus Type 2. It also stated R1 was unable to administer their own medications, including injections and own glucose testing. The management company did not complete a Preplacement Appraisal for R1. The licensee’s interview confirmed that they told the management company they were not present and if R1 required assistance with insulin, R1 would need to have someone do the insulin because the licensee was unavailable. The licensee also confirmed the caregivers are not allowed to do the insulin, as they are not skilled professionals. The licensee explained that the management company reported to the licensee that R1 was able to do their own insulin. The licensee made the management company aware, if R1 was not capable, the management company would need to hire a professional, or a family member. The licensee also stated they were told by the management company that R1 was alert and oriented, and R1 was able to manage their own insulin and capable of doing it. The Discharge Summary from the SNF included the following two (2) medications: Humalog Solution 100 Unit/ml (milliliter) (Insulin Lispro (Human) with instructions to inject per sliding scale subcutaneously with meals for diabetes; and Insulin Glargine Solution 100 Unit/ml, with instructions to inject 10 unit subcutaneously two times a day for diabetes. On March 6, 2025, the Home Health, Registered Nurse (RN) visited R1 at the facility. The RN reported that Staff #1 (S1) from BSM, LLC, Marketing were also present. The diabetic supplies on hand included two insulin pens, but there was no glucometer. The RN used their own glucometer to get blood sugar readings for R1, which measured at 190. The RN explained the home health staff are not providing 24-hour care, therefore, R1 themselves must be able to administer their own medication or receive assistance from the facility’s staff to take their medication. The RN explained to S1 that after taking the blood sugar reading, R1 needed to take their insulin, to which S1 acknowledged will be done, and placed the insulin in the refrigerator. On March 6, 2025, Staff #2 gave R1 their insulin pen, but did not observe R1 inject themselves. Continued on an LIC 9099C. On March 7, 2025, R1 reported to Staff #3 (S3) they were not feeling well and did not eat breakfast. R1 had a small amount of food for lunch and went back to sleep. At approximately between 3pm to 4pm, Staff #4 (S4) gave R1 their insulin pen, but S4 did not know the dosage the insulin pen was set at as there was no glucometer at the facility. S4 observed R1 inject insulin in their stomach. At approximately 6pm, R1 started to get restless. The Home Health agency was notified and instructed the facility to contact emergency services. R1 was transported to Hospital for evaluation. A review of the hospital records indicated the chief complaint was “Altered Mental Status.” The Emergency Department (ED) noted a Comprehensive Metabolic Panel: Glucose – 1264. The Mayo Clinic defines Hyperosmolar syndrome is caused by very high blood sugar that turns blood thick and syrupy. The Mayo Clinic also indicated blood sugar readings over 600 mg/dL are symptoms of a life-threatening condition. A review of the paramedic report documented upon arrival at the facility stated R1 was thrashing around their bed. The hospital’s Discharge Summary Report indicated drug-induced diabetes who presented to the emergency room March 7, 2025, with altered mentation and minimal responsiveness, found to have blood sugars in the 1200 range and diagnosed with hyperglycemic hyperosmic syndrome and diabetic ketoacidosis. R1 was admitted to the ICU (Intensive Care Unit), during which time they had an evolution of shock requiring three vasopressors, renal failure and respiratory failure. In setting maximum medical therapy with no improvement in clinical status and progressive multi organ dysfunction, R1 was transitioned to comfort focused measures for end-of-life care. R1 passed away at the hospital on 03/09/25. R1’s death certificate identified the cause of death as the following: Acute Encephalopathy; Hypovolemic Shock; Diabetes Mellitus Type I with Hyperosmolar Hyperglycemic State; and Small Cell Bladder Cancer. The medical records obtained were reviewed by the Department’s Program Clinical Consultant, Nurse Evaluator II. The nurse evaluator reported that not receiving insulin as prescribed is directly related to the development of Hyperosmolar Hyperglycemic State, which can then cause Acute Encephalopathy and Hypovolemic Shock. The nurse evaluator also reported these acute complications result from severe Hyperglycemia and dehydration that occurs when insulin is absent. The nurse evaluator explained if R1 received their insulin as prescribed while at the facility, it is possible R1 would still be alive. Continued on an LIC 9099C. Based on interviews conducted, and a review of pertinent records, corroborating evidence was obtained that staff neglect resulted in R1 ‘s death. Although staff reportedly gave R1 their insulin on March 6, 2025, only one facility staff member witnessed R1 injecting themselves with insulin while at the facility on March 7, 2025. In addition, interviews corroborate there was no glucometer for R1 to use at the facility. Without a glucometer, it is unknown how much insulin R1 actually needed during their time at the facility, and R1 was evaluated in the hospital with a glucose reading of 1264. In addition, R1 was admitted to the facility requiring a higher level of care due to the facility not having a present skilled professional to administer glucose testing and insulin injections. The preponderance of the evidence standard has been met, and the findings are substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Janette Monillas whose signature below confirms receipt of these rights. A Civil Penalty of $500 is being assessed for any violation that the department determines resulted in the injury or illness of a person in care. [See LIC 811 Confidential Names List to identify Resident #1]