complaint·April 17, 2021

This analyst reviewed a three-month sample menu supplied by the facility. The facility hires Crandall Corporated Dieticians to create the facility menu and it is designed to meet the dietary needs of residents with special dietary restrictions. The daily menu offers low-carb options and sugar-free dessert and beverage options. In addition to the daily menu, the facility also offers an "Always Available" menu that also includes other options for diabetics such as omelets, grilled chicken and baked fish. In addition, there is a salad bar option available at meals. Analyst interviewed four kitchen staff who state that there is a board in the kitchen and a binder with resident pictures and dietary restrictions to know what food to serve to each resident. Analyst also interviewed two other diabetic residents who stated that there were no issues in receiving meals that did not meet their dietary restrictions. Based on information obtained, Analyst finds the allegations to be UNFOUNDED – a finding meaning that the allegation was false, could not have happened and/or is without a reasonable basis. As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6. Exit interview conducted. Copy of report left with Activity Director Signature obtained on hard copy of report and placed in facility file. The complaint reports states that on 10/4/20 at approximately 5am R1 slipped from a recliner chair and "scooted" across to the bathroom to press the emergency call button. The report states that R1 waited until 7am for a first responder lift assist. Emergency call logs provided by the facility indicate that the call button was pushed at 6:33:36 am and staff responded to the resident at 6:41:13am. Per facility Fall Response Procedures, after assessing the resident a Med Tech may allow the resident to be assisted up to a chair if, the resident is able to bear weight. If resident is unable to bear weight, then then protocol is to call 911. Interviews with two caregivers and two med techs unfamiliar with the incident confirmed that R1 is unable to bear weight and in that incident 911 would be called in the event that R1 would fall. During a visit to the facility on 3/26/21, the facility was unable to provide any documentation of the series of events that occurred the night R1 fell. There is also no documentation when emergency responders arrived at the facility or an incident report that the event occurred. Based on the information obtained, there is insufficient evidence to determine how long R1 was on the floor or what staff did after discovering R1 on the floor. Analyst finds the allegation to be UNSUBSTANTIATED - a finding meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6. Exit interview conducted. Copy of report left with Activity Director Signature obtained on hard copy of this report and placed in facility file.