Resident 1 had worn the continuous glucose monitor since December 26, 2024, but Sunny Village Care Center didn't provide any training to licensed nurses until October 15, 2025 — nearly 10 months later. Even then, the training was incomplete and poorly documented.
"The majority of the licensed nurses told him that they were not properly trained in putting on and managing Resident 1's CGM device on him," according to the inspection report from the resident's interview on November 25.
The Director of Nursing admitted during a November 26 interview that she "did not think it was important to provide training to the nurses for application and monitoring of the CGM device as it is a personal device." She had assumed the resident could handle everything himself.
Only one Licensed Vocational Nurse in the entire facility felt confident enough to apply the glucose monitor to the resident's arm. But even that nurse couldn't operate the device's smartphone application to manage the resident's blood sugar data.
The facility's training, when it finally happened, consisted of watching online videos from a website. The Director of Nursing said licensed nurses would be evaluated through "return demonstration check-off" — but she couldn't provide any documented evidence that this evaluation ever occurred.
"The DON stated she could not provide documented evidence that a return demonstration check-off list and/or sign in sheet that licensed nurses undergone the training," inspectors found.
The technology gap extended beyond basic device application. Nurses never learned how to set up the glucose monitor's smartphone application to retrieve the resident's blood sugar data on the facility's phone system. This meant they couldn't monitor his glucose levels remotely, even though that capability existed.
The Director of Nursing acknowledged her own limitations with the technology. "The DON stated setting up the CGM device on a smartphone is new and involves high technology for her," the report noted.
She admitted the facility should have requested professional training from the glucose monitor company or the facility's pharmacy to conduct in-person training for licensed nurses. "The DON also stated she should have requested professional training from the CGM device company representative or from the facility's pharmacy to conduct an in-person training to the facility's licensed nurses but it was not done."
The training should have been completed by December 26, 2024, when the resident first received the device. Instead, the resident spent nearly 10 months in a facility where most nurses felt unprepared to help him with essential diabetic care equipment.
The facility's own policy requires staff to demonstrate competency in caring for resident needs. The policy, revised in August 2022, states that "all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law."
The policy specifically requires that "staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following area: person centered care." It also mandates that "competency requirements and training for nursing staff are established and monitored by nursing leadership."
The policy emphasizes that training programs should result in "nursing competency" and that "gaps in education are identified and addressed." It requires "tracking or other mechanisms are in place to evaluate effectiveness of training."
None of these requirements were met for the glucose monitoring device training.
When the resident's device became dislodged on November 15, he found himself in a facility where nurses openly admitted they lacked the training to help him. The device that was supposed to provide continuous monitoring of his blood sugar levels sat unused because staff felt unprepared to replace it.
The resident had been managing his diabetes with this technology for nearly a year, but the facility's failure to train nurses meant he couldn't count on staff assistance when he needed it most. The 10-month delay in providing even basic training left him essentially on his own for managing a critical aspect of his diabetic care.
The Director of Nursing's assumption that training wasn't necessary because the device was "personal" ignored the reality that residents sometimes need staff assistance with medical equipment, especially when devices become dislodged or malfunction.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunny Village Care Center from 2025-11-26 including all violations, facility responses, and corrective action plans.