Complaint·October 30, 2025

(Continued from LIC9099) Staff interviews revealed that on the date in question, Staff #1 (S1) prepared an insulin needle tip kit for Resident 1 (R1) in anticipation of administering insulin prior to an off-site outing. The needle safety guard was removed during preparation. However, R1 refused the injection, stating they would not be eating due to plans to dine out. S1 and R1 reported that the needle was not used, and the protective cap was replaced immediately. The needle was then placed in the medicine transport bag prepared for R1’s outing. Multiple staff confirmed that the needle remained unused and was not exposed to any blood, bodily fluids, or unclean surfaces. Records review revealed no documentation indicating improper disposal or contamination. LPA observations revealed that facility practices for medication preparation and transport were consistent with safe handling procedures. Based on a review of Title 22 regulations and infection control standards, the requirement to dispose of a needle generally applies when the needle has been used or is considered contaminated. In this case, the needle remained unused, capped, and was not compromised. Although the concern was acknowledged, there is insufficient evidence to support that the licensee failed to dispose of an injection needle as required. The needle was unused, not contaminated, and handled in a manner consistent with safe medication practices. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Cho, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided. (continued from LIC9099) Staff interviews revealed that Staff #1 (S1) had placed the resident’s glucose monitor in the medication cart after use. S1 acknowledged that the monitor was not returned to the resident’s bag prior to the outing but confirmed that the item was not lost or mishandled. LPA observations revealed that the glucose monitor was present and stored with other medical equipment on the medication cart. The investigation revealed that the glucose monitor was not missing but had been placed on the medication cart. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Administrator Cho, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.