Incident investigation·August 3, 2023

On 8/3/23 at approximately 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to an incident report for Resident 1 (R1). LPA Jensen met with Executive Director Gia Cocola and explained the purpose of today's visit. LPA Jensen reviewed 3 incident reports for R1. On 7/10/23, 7/15/23 and 7/17/23 R1 went to the emergency room for elevated blood sugar levels. LPA Jensen reviewed the LIC 602 which states that the resident is not able to administer his own medication or monitor his own glucose. LPA Jensen reviewed R1's need and service plan and it indicates that a licensed Practical/Vocational nurse will assist resident with glucose monitoring and insulin. LPA Jensen interviewed R1 who stated no one monitors his glucose and he administers his own insulin. LPA Jensen interviewed staff 1 (S1) and staff 2 (S2) and both confirmed that the resident administers his own insulin and is responsible for monitoring his own glucose. A deficiency is being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. The Executive Director stated the facility has an LVN on staff that has agreed to take over medication management for R1 effective immediately. An exit interview was conducted and a copy of this report, the LIC 811 and appeal rights were provided.