Complaint Investigation Report

LPA Chang interviewed R1. R1 stated he/she does not have insulin injections. R1 stated every 2 weeks the the blood sugar monitoring device is switched from his/her right/left arm to the other arm.

On December 17, 2025, LPA Manuel Monter interviewed staff S1-S6. 6 Out of 6 (S1-S6) staff stated the only people who can preform glucose testing is the nurse or the resident themselves. 6 Out of 6staff (S1-S6) stated he/she hasn’t seen any unqualified staff administering glucose testing.

On December 26, 2025, LPA Manuel Monter interviewed staff S7. S7 stated he/she has not observed anyone administer insulin or do glucose testing. S8 stated he/she doesn’t handle residents medications and isn’t aware regarding insulin or glucose testing.

On December 26, 2025, LPA Manuel Monter interviewed Residents R1. R1 stated he/she has a continuous glucose monitor, which sends the information to the app. R1 stated he/she doesn’t need to do any finger pricks or any form of injections to monitor his/her glucose. R1 stated he/she also takes medication tablets for his/her diabetes. R1 stated his/her family member is the person who switches the censors for him/her blood sugar monitor every 2 weeks.

On January 6 and 7, 2026, LPA Manuel Monter interviewed staff S8-S12. 3 Out of 5 staff (S8, S11, S12) stated they doesn’t handle residents medications and doesn’t know about residents insulin or glucose testing. S9 stated only a nurse can administer insulin or preform glucose testing. S10 stated the resident’s family does the switching of the glucose sensors. S10 stated he/she only marks it on the MAR.

On January 6, 2025, LPA Manuel Monter interviewed Wellness Director (WD) Angel Bustos. WD stated at the facility, they do not administer residents insulin. WD stated facility staff do not do any injections of any kind, and only the nurse can do this. WD stated she initially put the sensor for resident R1. WD stated R1’s family member was changing the sensor. WD stated the family changes the sensor, while the medtech gives the family the new sensor and marks it on the MAR.