complaint·February 11, 2026

Review of Physician Order (03/25/2025) revealed R1 was to start taking medication A and it was discontinued on 07/02/2025. Review of weight records revealed R1 weighed 208lbs (May 2025), 210lbs (June 2025), 209lbs (July 2025), 206lbs (Aug 2025), 201lbs (Sept 2025), 196lbs (Oct 2025), 190.6 lbs (Nov 2025), 186.6lbs (Dec 25), and 182lbs (Jan 2026). Record review of Physician Order (09/29/2025) revealed R1 to start taking medication A at the lowest dose and it was discontinued on 12/10/2025. Medical Assessment (12/10/2025) revealed R1 weighed 187lbs, is able to care for own toileting needs, able to feed self, but not able to leave the facility unsupervised. R1 is ambulatory. Summary visits revealed R1 was seen by doctor on 01/05/2026 and 01/21/2026 to address R1’s concerns. R1 was hospitalized from 01/31/2026 – 02/08/2026 to address R1’s concerns. Interview with both Chefs (S5 – S6), S1, Staff #4 (S4) indicated Mexican food is served at least weekly. Interview with S6 indicated Mexican food has been specifically purchased for R1 but R1 complained about the authenticity and quantity of food. Interview with S1 - S2 also indicated R1 eventually refused Mexican meals because R1 did not like the taste so Boost drinks was provided as a supplement. R1 stopped drinking the Boosts due to diarrhea. Interview with S1 - S2 indicated Resident #1 (R1) has been taking medication A that causes weight loss and decreased appetite. Six out of seven resident interviews (R1 – R7) indicated they are satisfied with the meals. LPA observed lunch (BBQ pulled pork on bun or grilled cheese, an Italian soup, coleslaw, and sweet potato fries) being served around 11:50 AM. LPA observed monthly menu posted in the dining room. Regarding the allegation, “Staff did not provide proper meals to resident in care resulting in weight loss,” based on record reviews, observation and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff did not change resident’s bedsheets . Record review of R1’s Admission Agreement (01/03/2023) revealed basic services include clean bed and bath linens weekly, or as often as needed and cleaning of resident's room. Plus bedside care and tray service for minor temporary illnesses or recovery from surgery. Four out of four staff interviews (S2 – S3, S7 – S8) indicated residents bed linen are changed weekly or whenever soiled. S2 indicated Resident #1 (R1) never complained about soiled linen. S2 indicated S3 notified S2 on 01/29/2026 that Resident #1’s (R1) toilet contained blood. R1 toilets independently and did not report toileting issues until S2 spoke with R1. Continue to LIC9099-C. S2 indicated staff observed blood on R1’s bed linen on 01/31/2026. S3 indicated R1’s linen was clean on 01/29/2026 but observed blood on 02/01/2026. Six out of seven resident interviews (R1 – R7) indicated bed linen is changed weekly and whenever soiled. LPA observed R1 sitting on bed that contained a white fitted sheet, a light green cushion pad, a sheet, blanket, and other items. Regarding the allegation, “Staff did not change resident’s bedsheets” based on record reviews, observations, and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Facility is unkempt Record review of R1’s Admission Agreement (01/03/2023) revealed basic services includes cleaning of resident's room. Interview with S1 – S2, S7 – S8 indicated the rooms are deep cleaned weekly. Six out of seven resident interviews (R1 – R7) indicated housekeeping is completed weekly and they are satisfied. LPA observed the common areas to be clean and housekeepers cleaning residents’ rooms. Regarding the allegation, “Facility is unkempt,” based on record reviews, observations and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to Administrator Assistant Linda Cardenas.