complaint·July 23, 2021

On 06/24/2021 when asked if they had a fall at facility on 06/16/2021 R1 stated "I don't know, I do not remember." On 07/23/2021 the administrator stated that "R1 did not fall on 06/16/2021 but was found unresponsive in their bed." On 07/23/2021 staff S7 stated that "I saw R1 in bed unresponsive on 06/16/2021 and I reported it to med tech S3. Regarding the allegation: “Resident suffered falls while in care.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation:” Staff did not properly administer insulin to resident.” On 06/18/2021 the department received information that R1 was given insulin on an empty stomach. On 06/24/2021 when asked if they ate dinner the night before the incident R1 stated “yes". During today’s visit the administrator stated that R1 administers own insulin injections and staff only provides assistance. Regarding the allegation” Staff did not properly administer insulin to resident.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: “Staff not feeding resident.” On 06/24/2021 witness W2 stated "R1 does not like the food at the facility and refuses meals often " Staff S3 stated “R1 refuses meals." Staff S6 stated "We have a list of residents who goes out on dialysis. Staff delivers meals to their rooms, for example if they go in the morning and are out all day, we deliver lunch and dinner to them." R1 stated “When I do not like the food or when I have no appetite. My family also brings me food." On 07/22/2021 10 out of 10 residents interviewed denied not being given food by staff during meals. Regarding the allegation: “Staff not feeding resident.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report was provided to Ginger Enriquez, the administrator.