complaint·September 15, 2025

Continued form LIC 9099 Regarding the allegation: “Staff did not ensure resident received adequate nutrition” it was alleged that Resident #1 (R1) is only receiving three feedings per day and is not getting enough nutrition. R1 has a documented medical diagnosis of swallowing difficulties involving the mouth and throat (Sever Dysphagia). Due to this condition, R1 was prescribed a liquid special diet “NPO” (nil per os, nothing by moth) and long-term use of artificial nutrition upon admission to the facility in August 2024. The current hospice plan of care indicates that R1 is to be fed three (3) times daily using 4 to 4 1/2 cartons of Jevity 1.5 Calories per mL. of a doctor-prescribed liquid diet containing complete balanced nutrition and fiber. The Hospice Nurse (HN) stated that R1 is capable of communicating any discomfort or intolerance during feeding sessions, and that R1 remains alert, oriented and active throughout the day, including exercising and taking short walks. LPA requested weight logs and was informed by the HN that R1 is weighed approximately once every two (2) weeks. Records provided show an average weight of 137.5 as of September 12, 2025, with an increase in muscle mass based on latest measurement. At admission, R1 weighed 128 lbs. In an interview, R1 expressed satisfaction with the amount of liquid nutrition received, though R1 stated they would prefer solid food if possible. R1 also demonstrated understanding of their medical condition and dietary requirements. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violations occurred; therefore, the allegations “Staff did not ensure resident received adequate nutrition” is deemed unsubstantiated at this time. Regarding the allegation of “Staff did not assist resident with bathing as needed” it was reported that Resident #1 (R1) often becomes sweaty; however, staff provide showers twice a week. Back up administrator reported that R1 is receiving hospice services, which include bathing twice a week. R1 is being seen by Hospice Nurse (HN) who visits every Tuesday and Friday, and a Hospice Aide (HA) who visits every Monday and Thursday. The HA provides showers. During today’s visit, the HA was present at the facility assisting R1. In an interview, the HA confirmed that R1 receives two (2) full showers each week in accordance with their established care plan. The aide, who has been caring for R1 since March 2025, denied ever observing R1 soiled, unclean, or with body odor. Continued on LIC 9099-C Continued on LIC 9099-C Additional staff interviews reflected that caregivers assist R1 with bathing support as needed, including when R1 is sweating or after an “accident”. LPA conducted a private interview with R1 in their room. R1 stated that they would like to receive full showers more frequently but acknowledged that they have not made this request to caregivers, the administrator, agency nurses, or the back-up administrator. During observation, LPA noted that R1 appeared clean-shaved, wearing a clean shirt and no body odor was detected. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violations occurred; therefore, the allegations “Staff did not assist resident with bathing as needed” is deemed unsubstantiated at this time. Exit interview was conducted. A copy of the report was provided via e-mail.