complaint·May 22, 2025

Regarding the allegation, “Resident lost significant amount of weight”. It is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and the facility isolated the resident for four weeks. During the isolation period the resident lost a lot of weight, from about 112 lbs. R1 dropped to 103 lbs. and went from a size 6 to a size 2. File review revealed that Resident #1 (R1) was admitted to the facility on 1/13/24. Per R1’s Monthly Vital Signs and Weight Record, on 1/25/24, R1 weighed in at 121 lbs. and on 07/25/24 (shortly after the complaint was submitted), R1 weighed in at 108 lbs. This is a 13 lbs. weight loss within a 6-month period. Furthermore, R1 weighed in at 114 lbs. on 5/31/24, having a 6 lbs. weight loss within 2 months. The community’s Charting Notes starting on 5/17/2024 and ending on 08/05/2024 indicated that during that time frame R1 was being treated for Scabies, placed on isolation on 05/30/24 until MD gives clearance to leave, on 06/26/24 an order was received from residents PCP that R1 was able to come off isolation, and on 07/06/24 PCP was notified that R1 will be in isolation. However, R1’s charting notes did not reflect any doctor appointments to address the issues with weight loss, additionally no mention of weight loss was charted on these notes. Interview conducted by LPA Camara with the ED on 07/25/24, revealed that the ED was not aware R1 had lost so much weight and suspected it could have been muscle loss due to the isolation period because R1 is normally quite active, and the ED planned on asking R1’s doctor if they should put R1 on Ensure to get some weight back on them. Interview conducted by LPA Camera with R1’s Primary Care Physician (PCP) revealed that they do not weigh the resident because they are mobile, but that they had not realized R1 had lost that weight and was not aware of a medical cause for the weight loss. File review did not indicate any notification of weight loss to R1’s PCP by the community. During today's visit, Business Office Director was not able to provide any records of staff addressing R1's weight loss in 2024 with their PCP. Based on file review and interviews, the Department has sufficient evidence to support the allegation, therefore the allegation Resident lost significant amount of weight is Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22 (See LIC9099-D.). Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided Regarding the allegations, “Resident contracted scabies while in care and Resident developed sores while in care”; It is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and R1 had scabs/sores on their back from scratching. File review revealed that on 05/30/24, R1’s Primary Care Physician (PCP) was notified that R1 was noted scratching chest, upper/lower back, small dry red/brown spots were noted, pictures were sent over, and PCP was asked to please advise. Interviews with the ED, staff, R1’s PCP and charting notes revealed that R1 was diagnosed with Scabies/suspected Scabies on 05/30/24 by their Primary Care Physician and was prescribed treatment. File review revealed that staff addressed R1’s rash and were following R1’s orders. The ED revealed that R1’s Power of Attorney (POA) made different Dermatology appointments and R1’s reoccurring rash ended not being scabies. Interview conducted with R1’’s POA revealed that the error came from R1’s PCP who misdiagnosed R1 with Scabies, they took R1 to several Dermatologist and R1 had a bacterial infection and recovered after they were given antibiotics. A review of an Urgent Care Center doctors order dated 08/01/24, indicated that R1 did not have a rash due to scabies. Information obtained from file reviewed and interviews conducted revealed R1 was diagnosed with Scabies/possible scabies and presented a rash on their back, however R1 was being seen and treated by their PCP. Staff interviews also revealed that staff was following facilities Scabies protocol, and all doctor’s orders. Therefore, the allegations are deemed Unsubstantiated at this time. Exit interview conducted and report issued.