The resident, identified as Resident 3 in federal inspection records, dropped from 219 pounds in September to 173 pounds by February, a 23.29% weight loss. During one stretch from January to February, he lost 33 pounds in just 44 days.
Federal inspectors found the facility failed to follow its own protocols for monitoring residents with significant weight changes. When a resident loses 5% or more of their body weight, staff are supposed to immediately initiate a "change of condition" evaluation that includes notifying the physician and legal representative.
Nobody did.
The resident had been battling C. diff infections and gastroesophageal reflux disease. By November, an automated assessment flagged his 9.1% monthly weight loss and recommended a dietitian consultation. The consultation didn't happen until December 3 — nearly three weeks later.
A second resident experienced similar neglect. Resident 4 lost 17 pounds in one month, dropping from 140 to 123 pounds — a 12.14% decline. Staff were ordered to monitor his weight weekly for three weeks due to the significant loss.
They didn't follow through.
After weighing him on March 14, staff didn't check his weight again until April 1, missing two full weeks of the ordered monitoring. The resident told inspectors on April 17 that he knew he was losing weight but had no idea how much.
"There was no discussion on how much weight he had lost, and what the facility was implementing regarding the weight loss," he said. "He would like to gain his weight back."
The facility's registered dietitian acknowledged the failures during interviews with inspectors. She confirmed that significant weight loss triggers specific protocols but admitted she never notified the physician about Resident 3's 51-pound loss over six months.
The Director of Nursing explained the facility's policy during the inspection: when a resident loses 5% or more of their body weight, staff should immediately initiate change of condition protocols. This includes monitoring the resident, notifying the physician and legal representative, ordering a dietitian consultation, and conducting an interdisciplinary team evaluation.
"Once the weight was entered into the medical records, the COC should be done immediately," the Director of Nursing told inspectors.
For Resident 3, the interdisciplinary care conference didn't happen until March 12 — 24 days after he had already lost 33 pounds in the previous six weeks. The conference noted a "weight variance of -32 lbs" but the damage was already done.
The facility had implemented some interventions for Resident 3, including physician orders for snacks at 2 p.m. and 8 p.m., oral nutrition supplements twice daily, and weekly weight monitoring. But these measures came only after months of documented weight loss without proper oversight.
Resident 4 received similar late interventions. His care plan from March 18 included daily multivitamins, protein supplement beverages, and weekly weight monitoring — but only after he had already lost 17 pounds in a single month.
Both residents had care plans acknowledging their risk for weight loss. Resident 3's plan noted he was "at risk for weight loss, nutrition, hydration, skin integrity complication related to his current health, therapeutic diet and history of c-diff episodes." The interventions included having staff assist during meals and monitor nutrition intake and weights "per protocol."
The protocol wasn't followed.
Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" but noted the failures "posed the risk of nutritional interventions not being implemented in a timely manner and cause the residents to have further weight loss."
Resident 3 was transferred to an acute care hospital on April 16, one day before inspectors arrived at the facility. His final recorded weight at Pelican Ridge was 168 pounds — 51 pounds less than when his dramatic weight loss began six months earlier.
The Administrator and Director of Nursing acknowledged the inspection findings on April 18.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Ridge Post Acute from 2025-04-18 including all violations, facility responses, and corrective action plans.