Complaint·November 10, 2025

(Continued form LIC9099) On October 22, 2025 it was reported to Community Care Licensing(CCLD) that staff do not follow doctor’s orders. More specifically,  the reporting party (RP) alleged that on October 14, 2025, staff attempted to administer insulin to R1 at 7:00 AM, prior to the resident eating, which the RP believed was inconsistent with the physician’s orders. Staff interviews confirmed that on 10/14/25, a med-tech checked R1’s blood sugar around 7:00 AM but did not administer insulin.  A second staff member, who was present at the time,  clarified that insulin is only administered as per physicians' orders. Records review confirmed that insulin was not administered during the 10/14/25 incident and that staff reviewed insulin timing procedures afterward. LPA observations confirmed that insulin administration protocols were posted and understood by staff. It was further alleged staff do not ensure resident is receiving medication as prescribed. More specifically, that during the resident’s COVID isolation period (August 4–5, 2025), staff failed to monitor the resident adequately, resulting in a low blood sugar episode. Staff interviews confirmed that insulin and glucose monitoring  were provided to R1 during that time. Resident interviews did not indicate missed medications. Records review of the MAR showed consistent documentation of insulin administration and blood glucose monitoring. Progress notes from August 2025 documented a hypoglycemic event that was treated appropriately and reported to the POA. LPA observations confirmed that medication storage and documentation practices were in place. It was further alleged staff did not ensure resident’s representative was notified of a change in condition in a timely manner. More specifically, RP stated that on October 18, 2025, the resident was reportedly unresponsive with a high blood sugar reading, and the RP was not notified until several hours later via email. Staff interviews confirm that all POA's are notified per CCLD regulations.  Reporting party c onfirmed that they received an email at 3:00 PM regarding an incident that occurred around 11:30 AM. Records review confirmed the incident and the email communication but did not include documentation of a phone call or earlier notification. There was no evidence of harm or a pattern of delayed notification. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegation is UNSUBSTANTIATED An exit interview was conducted with Executive Director Cho, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided .