complaint·March 16, 2026

CONTINUE FROM LIC9099 Allegation: Staff did not ensure resident received adequate nourishment, resulting in significant weight loss It was reported to the department that R1 was not receiving adequate nourishment which caused R1 significant weight loss. Interview with W1 and W2 revealed that R1 lost weight W1 reported that W2 was the one that noticed, one day W2 was at the facility and witnessed R1 shoulder that looked like R1 was smaller, W2 stated that W2 is not sure how R1 had gotten smaller. W2 stated that W2 made sure R1 ate when W2 was at the facility. W2 brought it to the facilities attention and S1 and W2 agreed that the facility would now start to provide R1 with a Ensure Protein shake. S2 stated that R1 was tall and skinny when R1 was admitted to the facility. S2 also stated that R1 would eat 100% of R1’s breakfast and a good amount of R1’s lunch but would eat less dinner some times as low as 30 to 40%. S2 stated that W1 and W2 would visit the facility 3 to 4 days a week at lunch time and would also eat lunch with R1. S3 reported that R1 would always eat 100% of R1’s breakfast, S3 also reported that R1 would often feed R1’s self and on some days staff would feed R1. S3 also reported that R1 had a special diet and the facility staff would follow the physicians orders. S4 stated that the facility dose clean eating, well balanced meals, the facility provided R1 with the protein shakes. S4 stated that the family is very protective and S1 or S4 would contact the family with any changes or incidents that happened with R1. LPA conducted a record review the LIC 602 stated that R1 was on a special diet, the resident’s daily food chart shows that R1 ate 100% of breakfast and 50 to 100% of lunch and 50 to 100% of dinner. Progress notes revealed that R1 was diagnosed with moderate protein calorie malnutrition upon admission. THEREFORE THIS ALLEGATION IS UNSUBSTANTIATED. CONTINUE ON LIC9099C CONTINUE FROM LIC9099C Allegation: Staff do not ensure that resident's responsible party is notified of changes in condition It was reported to the department that R1 had a change in condition and it was not reported to the RP. During the investigation LPA interviewed W1, W2, S1 , S2, S3, and S4. W1 stated that W1 was not really aware of what happened because W2 was in charge of R1’s medical care. W2 reported that R1 had a change in condition and W2 was not informed of the changes. S1 stated that S2 reported to S1 that R1 has a red area on R1 Coccyx area. The family had a home health nurse that would visit R1 3 times a week, S2 stated that the home health nurse visited R1 and provided the facility with a medication to apply to the area. W2 came to the facility and staff showed W2 the photo of the area where R1 skin was red and had cream on it. W2 then contacted S1 complaining that R1 had a red area that was not reported to W2. S1 stated that W2 visited that facility before S1 was able to call R1 to report that R1 had the red area on R1 Coccyx area. S1 reported it was within 24 hours. S1 also reported that the cream was applied and the area was no longer red after 3 days. S1 stated that they didn’t have record of home health documentation because they were visiting the facility at the families request. Staff showed W2 photos and reported the issue to W2. THEREFORE THIS ALLEGATION IS UNSUBSTANTIATED. CONTINUE ON LIC9099C CONTINUE FROM LIC9099C Allegation: Staff did not prevent resident from sustaining a pressure injury It was reported to the department that R1 had developed a pressure injury. During the investigation LPA interviewed W1, W2, S1, S2, S3 and S4. W1 stated that W2 handles all R1’s medical needs and W1 would have more information. W2 stated that the facility was not turning R1 as they should every 2 hours. W2 stated that R1 was complaining about R1’s back was hurting and W2 was asking staff to help reposition R1. S1 stated that staff are scheduled to reposition residents every 2 hours. S1 stated that W2 wanted night care for R1 S1 stated that it would be a fee for night care services. W2 did not want to pay the additional fees, S1 stated that the facility absorbed the cost and R1 was repositioned every 2 hours. S2 stated that the facility staff repositioned R1 every 2 hours and the S2 suggested a particular kind of wedge for night time and S2 stated that the family stated it was too pricy. S2 stated that night time S2 would be sure to change and reposition R1. S3 stated that a nurse came from John Muir and treated the red area on R1 and it was cleared within 3 days. S3 stated that staff would reposition R1 during the night every 2 hours, staff would follow all directions. S3 stated that the family had R1 on a exercise program and staff followed all directions. S4 stated that the facility had R1 on a exercise program and all staff would follow all instructions provided by family. S4 stated that family didn’t want to pay for night care so the facility absorbed the cost and provided night care. The facility provided 24 hour care, exercising , changing and repositioning the resident. LPA conducted record review R1 LIC 602 which revealed that R1 has a history of skin condition or breakdown and there is an order for a medication to apply to the area, progress note also revealed that the skin on the Coccyx has pink blanchable scar tissue which was intact, but noted high risk for pressure injuries. LPA also viewed the photos and the area was red but the skin was not broken. LPA requested the John Muir nurse documentation from the family which was not received. THEREFORE THIS ALLEGATION IS UNSUBSTANTIATED. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided .