Heritage Manor: Diabetes Medication Gap Causes High Blood Sugar - CA
The consultant pharmacist reviewed Resident 1's medication regimen for the month of July 2025. His only recommendation was about gabapentin, a nerve pain drug, and a question about how it was being administered. He flagged nothing about diabetes. No insulin. No metformin. No note that a resident with type 2 diabetes appeared to be receiving no treatment for it.
When inspectors reached him by phone on August 14, the pharmacist explained why. He said Resident 1's diabetes diagnosis was not included in the list of diagnoses he was given to review. He confirmed the resident had received insulin during a previous stay at the same facility. He said he had not looked at the hospital records from the new admission, had not reviewed laboratory results, and described his approach plainly: "I would only review hospital records, laboratory results, and doctor's notes if there's something that I would clarify, so it's only sometimes, not all the time."
An hour later, he called back. He said he did not have access to Resident 1's full diagnosis list. He said that if he had known about the diabetes diagnosis, he would have flagged the missing medication in July's report. He said he would have pulled the lab results. He said he would have caught it.
The Director of Nursing confirmed that the pharmacist's review in July was not comprehensive, and said the pharmacist should have gone back to Resident 1's previous medication orders from the prior admission. She said he should have reviewed the hospital records connected to the July readmission. She added that licensed nurses also failed to review Resident 1's health history and medications when the resident was admitted on July 14, 2025.
Resident 1 was readmitted to Heritage Manor in July with a diagnosis list that included type 2 diabetes with hyperglycemia, a gastrostomy tube for feedings, and difficulty swallowing. A July assessment noted the resident had moderately impaired cognitive skills and was fully dependent on staff for bathing, dressing, hygiene, and toileting. The resident could not advocate for a missing prescription. Nobody else did either.
The facility's own medication review policy, last updated in June 2021, states that the consultant pharmacist performs a comprehensive review at least monthly and that the facility is responsible for ensuring the pharmacist has access to residents and their complete medical records. The pharmacist did not have that access. The review happened anyway, and it found nothing wrong.
The gap between what the policy promised and what the pharmacist actually had in front of him sat undetected for weeks, until August 9, when Resident 1's blood sugar climbed high enough that it showed up in the record as hyperglycemia.
Inspectors cited the facility for failing to conduct a comprehensive medication regimen review in accordance with its own procedures, noting the deficient practice directly caused Resident 1's hyperglycemia. The citation was cross-referenced to findings about care planning, quality of care, and nursing competency.
Resident 1 came back to Heritage Manor already carrying the diagnosis from a previous stay there, already having been prescribed insulin in those same halls. The pharmacist who reviewed the medications that July had worked with this resident before. The records existed. The history existed. What did not exist, apparently, was a system that made sure he could see any of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Manor from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 22, 2026 · Our methodology
HERITAGE MANOR in MONTEREY PARK, CA was cited for violations during a health inspection on August 14, 2025.
The consultant pharmacist reviewed Resident 1's medication regimen for the month of July 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.