Pasadena Grove Health: Insulin Refusal Unreported to Doctor - CA
The resident, identified in inspection records only as Resident 1, requires Insulin Glargine, a long-acting insulin used when the body cannot produce enough of its own. When she refused doses, staff did not notify her attending physician. When she refused blood glucose monitoring, that went unreported too. The facility's own Director of Nursing told inspectors what that silence could mean: without insulin, Resident 1 could go into a diabetic coma.
The inspection, conducted September 3, 2025, was triggered by a complaint. Federal inspectors cited the facility under F0755, which covers medication administration and pharmacy services. The level of harm was recorded as minimal harm or potential for actual harm, affecting some residents.
The Director of Nursing did not dispute what happened. She confirmed the interdisciplinary team, the group of clinical staff responsible for coordinating a resident's care, should have addressed Resident 1's refusals and did not. The refusals were not worked into any updated care plan. No alternative treatments were offered, as far as the record shows. The team simply did not act.
Pasadena Grove had a written policy for exactly this situation. Its Refusal of Treatment procedure, last revised in May 2023, spelled out what staff were supposed to do every time a resident declined a medication or treatment: document the date and time, the specific medication refused, the resident's stated reason, the name of the staff member who attempted administration, confirmation that the resident was told why the medication mattered and what skipping it could cause, the resident's condition afterward, and the date and time the attending physician was notified along with that physician's response.
None of that happened. The physician was not notified. The consequences were not documented. The refusals accumulated without a clinical response.
The facility had a second relevant policy, its Medication Administration procedure, revised in November 2017. That policy addressed medications like Insulin Glargine directly: when a drug depends on prior testing, such as a blood glucose reading, the testing must be completed and recorded before the medication is given. Blood sugar monitoring and insulin dosing are inseparable in diabetic care. If a patient refuses the finger-stick check, the dose cannot safely proceed. If she refuses both, a physician needs to know.
Resident 1 refused both. Her doctor did not know.
What the inspection record does not say is how many doses were missed, how long the refusals continued, or what Resident 1's blood sugar levels were during that period. It does not say whether she experienced any symptoms. It does not name the nurses who attempted administration, the charge nurse on duty, or the physician who should have received a call. The record is thin on those specifics. What it does establish, through the Director of Nursing's own words, is that the gap between what the facility's policies required and what staff actually did was not a matter of interpretation. The DON knew the protocol existed. She knew it had not been followed.
For a resident whose body cannot regulate its own blood sugar, that gap is not administrative. Uncontrolled hyperglycemia, blood sugar that climbs without insulin to bring it down, can progress to diabetic ketoacidosis or hyperosmolar hyperglycemic state, both of which can cause loss of consciousness. The Director of Nursing used the word coma. She used it to describe what could happen to Resident 1.
Inspectors reviewed the facility's policies and found them sound. The problem was not that Pasadena Grove lacked a procedure for handling medication refusals. The problem was that the procedure existed on paper and stopped there. The interdisciplinary team, the charge nurse, the Director of Nursing, all of them knew what the policy required. The physician who needed to know about his patient's refusals still had not been told by the time inspectors arrived.
Resident 1's doctor received no call. Her care plan was not updated. Whether her blood sugar was ever checked during the period of refusals, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pasadena Grove Health Center from 2025-09-03 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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
PASADENA GROVE HEALTH CENTER in PASADENA, CA was cited for violations during a health inspection on September 3, 2025.
When she refused doses, staff did not notify her attending physician.
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.