It was reported Resident 1 (R1) has lost about 40 lbs. in a year.

LPA reviewed 5/28/25 diet order from VA: Minced Moist MM5, Ensure Plus QD. Facility care plan states special dietary needs soft to chew minced and moist. Weight history for R1: 12/06/2023 172.6 lbs., 01/05/2026 137.6 lbs. VA Interdisciplinary plan states difficulty chewing. Goals/Outcomes X 90 days: Intake of adequate calories, protein and fluids by following a texture modified diet. Interventions (for patient and/or caregiver): Registered Dietician (RD) to provide assisted living facility (ALF) with dietary information on preparing texturized foods as needed.

VA RN interview stated they did not know that R1 did not have a top denture and had they known they would have ordered a pureed diet for R1.

All staff that were interviewed stated that R1 has not had a top denture since they moved into the facility.

ED stated that R1 had an ill-fitting top denture when they moved into the facility and R1’s responsible party did not want R1 fitted for a new denture. The VA has changed R1’s diet and R1 is always given extra portions because R1 is always very hungry. R1 consistently drinks Ensure, eats extra portions and snacks . Per ED R1 has a soft and easy to chew diet.

It was determined that the facility knew that R1 did not have a top denture and did not communicate this to the VA which resulted in R1 not being prescribed the correct modified diet by the VA. R1 has lost a significant amount of weight. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell.

It was reported that Resident 1 (R1) has a history of repeated falls, requires assistance with all transfers and toileting with most falls occurring when R1 attempts to toilet or transfer themselves.

LPA reviewed seven incident reports for falls from April 2025 to January 2026. Two resulted in skin tears and first aid was provided. The remaining five falls were reported as non-injurious. R1 fell out of their wheelchair 3 times, was found on the floor next to their bed twice, and was found on bathroom floor twice (once in common area bathroom).

LPA reviewed 90-day home care interdisciplinary treatment plan from the VA dated 01/14/2026 which states R1 is non-ambulatory with a high fall risk and requires caregivers to assist with all transfers. Plan states history of falls in association with lack of care giver oversight.

VA RN stated R1 has had several falls and now facility staff are checking on R1 every two hours which is required especially during the night. RN states that R1 has had too many falls from their wheelchair so they worked with VA occupational therapy and added a wheelchair alarm.

Staff interviews revealed that R1 has had falls but none resulted in any injury that required treatment beyond first aid. All staff stated they had been trained on the correct way to transfer R1. R1 uses a wheelchair alarm.

ED stated that R1 has experienced falls and the facility has increased checks on R1 especially during the PM shift and R1 is toileted more frequently to include before and after meals. The VA ordered a wheelchair alarm for R1 and the facility has implemented its use.

It was determined that although R1 has a history of non-injury falls those falls have decreased over the past two months after the facility implemented the VA requirement to increase checks for R1 especially in the night, and have added the wheelchair alarm that the VA requires. This allegation is unsubstantiated.

It was reported that staff are not implementing the care plan for Resident 1 (R1).

LPA reviewed two interdisciplinary care plans for the dates of 05/28/2025 and 01/26/2026 for R1.

VA RN stated there is a binder in the facility that contains the interdisciplinary care plans and every time the RN visits they update the binder with the new care plan which includes care plans for the dietician, physical therapist, RN and an emergency care plan. States every time they are at the facility they discuss their observations with facility staff.

Staff stated they follow all care plans for R1.

ED stated that R1 is on the home-based home care program through the VA and the VA provides these services at the facility. The VA care plan and notes from their visits are placed in a separate binder for the VA. Our staff implement anything the VA wants in the facility care plan.

It was determined that the VA provides interdisciplinary care plans and notes to the facility and staff follows those plans. This allegation is unsubstantiated.

This agency has investigated the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted and a copy of the report was provided to administrator Nicole Braswell.