Health inspection·December 10, 2025

The following reflects the findings of the California Department of Public Health during a recertification survey Event ID: 1D13C0-H1 State Citation A was written 22 CCR 72311 (a)(2)(3)(D) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient's licensed healthcare practitioner acting within the scope of his or her professional licensure. 42 C.F.R. 483.25(g) (1) (g) Assisted nutrition and hydration. (Include naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- 483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. On 7/21/25 at 9:00 a.m. an unannounced recertification survey was conducted at the facility. The facility failed to 1. Recommend and implement interventions to prevent weight loss in a timely manner. 2. Notify the physician, Resident 41's responsible party (RP), schedule an inter-disciplinary team (IDT-a group of professionals from different fields who collaborate to achieve a common goal) to determine the cause of the weight loss in accordance with professional standards of practice 3. The facility failed to follow and the facility's policy and procedure, "Weight Management Policy" These failures resulted in Resident 41 experiencing an unplanned weight loss of six pounds (3.4%) in one month (2/1/25-3/1/25), nine pounds (5.3%) in one month (5/1/25-6/1/25), and 23 pounds (13.7%) in five months (2/1/25 - 7/7/25). These failures had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), loss of independence, and decreased quality of life. During a review of Resident 41 s "Admission Record" (document containing resident demographic information and medical diagnosis) dated 7/24/25, indicated Resident 41 was admitted to the facility on 4/12/23 with diagnoses of dysphagia (difficulty in swallowing), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety (a feeling of unease, worry or fear) and unspecific protein-caloric malnutrition ( a condition resulting from insufficient intake of protein and/or calories). During a review of Resident 41s "Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment)," dated 7/7/25, the "MDS," indicated Resident 41's Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 99, indicating Resident 41 was unable to complete the interview. During a review of Resident 41's "MDS" section GG (standardized functional assessment used in all post-acute care settings to measure self-care and mobility) dated 3/2/25, the MDS indicated Resident 41 required partial/moderate assistance (helper does less than half) with eating. During a review of Resident 41's "MDS" section GG dated 5/29/25, the MDS indicated Resident 41 required substantial/maximum assistance with feeding (helper does more than half) with eating. During a review of Resident 41's "MDS" dated 7/7/25, the MDS indicated Resident 41's weight was 153 pounds and was not on physician prescribed weight loss regimen. During a record review of Resident 41's "Weights and Vitals Summary" from 2/1/25 to 7/7/25, the following monthly weights for Resident 41 were shown: 2/1/25: 176 lbs (pounds-unit of measurement): 3/1/25: 170 lbs (3. 4%, -6 lbs weight loss in 30 days compared to previous month 176 lbs.). 4/1/25: 171 lbs 5/1/25: 169 lbs 6/1/25: 160 lbs (5.3% , 9 lbs weight loss in 1 month compared to previous month 169 lbs) 6/23/25: 156 lbs (2.5%, -4 lbs in 3 weeks compared to 160 lbs on 6/1/25) 7/7/25: 153 lbs (13.7%, 23 lbs weight loss compared to 176 lbs on 2/1/25). 7/14/25: 151 lbs During an observation on 07/21/2025 at 10:22 a.m. in Resident 41's room, Resident 41 was lying in her bed. Resident 41 was dressed in a gown. Resident 41 was not able to state her name and was not interviewable. During a concurrent interview and record review on 7/23/25 11:47 a.m., with License Vocational Nurse (LVN), Resident 41's Registered Dietitian's Progress Notes (PN) dated 7/15/25 was reviewed. The PN indicated, "...Dietary: 7/7: 153lb, 3 lb weight loss x 2 weeks (6/26:156lb) and significant 14% 25 lb weight loss x 6 month (1/1:178lb) ...IDT recommendation: continue with plan of care and monitor weekly weight x 1 week..." LVN 1 stated an IDT should have discussed Resident 41's weight loss. LVN 1 stated the IDT should have recommended any changes for the residents and the nurses should have followed the recommendations. LVN 1 stated she was not aware she had to notify the physician of Resident 41's weight loss on 6/1/25 and 7/7/25. During an interview and record review on 7/24/25 at 2:20 p.m. with the Registered Dietitian (RD), the RD stated Resident 41 had a six-pound weight loss in one month on 3/1/25. The RD stated the facility should have had an IDT meeting in the month of 3/1/25 and was not done. The RD stated she should have made recommendations for weekly weight check in 3/2025. The RD stated on 6/1/25 Resident 41 had a nine-pound weight loss. The RD stated on 6/12/25 there was an IDT meeting and Resident 41 was added to the weekly weight and weight variance program (system for monitoring and addressing significant weight changes in residents, especially weight loss, to ensure their health and well-being). The RD stated Resident weight was 160 lbs. on 6/1/25 and on 6/23/25 her weight was 156 lb. The RD stated Resident 41 had four pounds weight loss in three weeks. The RD stated Resident 41 was started on [brand name of protein supplement] (collagen protein medical food used to address increased protein needs in individuals with conditions like pressure injuries, wounds, and protein-energy malnutrition) for supplement on 7/21/25. The RD stated Resident 41 had a significant weight loss and should have additional supplement on 6/25. The RD stated the facility should have done a diabetic oral supplement to prevent weight loss. The RD stated she did not do all the interventions to prevent weight loss. The RD stated the physician should have been notified of the weight loss on 6/1/25. During an interview on 7/24/25 at 2:50 p.m. with the Speech Therapist (ST), the ST stated Resident 41 had a fall and was not eating after returning from the hospital. The ST stated she was asked to evaluate Resident 41 swallowing. The ST stated she recommended a downgrade to pureed diet. The ST stated Resident 41 had weight loss. During an interview on 7/24/25 at 4:16 p.m. with the Administrator in Training (AIT), the AIT stated Resident 41's weight loss should have been discussed in the IDT meeting on 3/1/25. The AIT stated the RD should have implemented interventions to prevent further weight loss. The AIT stated he was not notified of the weight loss on 6/2025 and 7/2025. The AIT stated he was not part of the IDT meeting. The AIT stated the weight loss should have been discussed during stand up (a short, daily meeting where team members quickly update each other on their progress and any roadblocks they're facing). The AIT stated all team members including himself should have been notified of the weight loss. The AIT stated it was important to notify all team members so residents would not have further weight loss. The AIT stated the weight loss could have contributed to residents eating less, eventually declining and dying. During an interview on 7/24/25 at 5:30 p.m. with the Director of Nursing (DON) the DON stated she expected Resident 41's weight loss to be addressed. The DON stated the nurses should have contacted the physician [ and responsible party (R/P) right away about weight loss. The DON stated an IDT meeting with progress notes should have been done and there should have been documentation in the medical chart. The DON stated a change in condition (a noticeable alteration in a person's physical or mental state or in the circumstances surrounding a situation) should have been done. The DON stated the change of condition should be initiated on 3/1/25 with the first six pounds loss being identified. The DON stated the nurses should have documented the physician and R/P were notified on 6/1/25. The DON stated an IDT meeting should have been held on 3/2025 for the weight loss. The DON stated IDT should have been done weekly. The DON stated an IDT meeting was not done on time. The DON stated the IDT meeting should have been conducted on 6/14/25. The DON stated the physician should have been notified to recommend interventions to prevent further weight loss. The DON stated she should have monitored the intervention to see if it was effective. The DON stated the facility did not follow the weight management policy and procedure. During a review of Resident 41's "Care plan Report" undated, the Care Plan indicated, "[box interventions/task] if weight decline persists, contact physician and dietician immediately...Determine percentage lost and follow facility protocol for weight loss..." During a review of Resident 41's "Skilled Nursing Nutrition Risk Review Form" dated 3/5/25 the Skilled Nursing Nutrition Risk Review Form indicated, "...Admission weight185 lb...Most recent weight: 170 lb...Usual body weight (UBW): 172-187 lb..." There were no supplement recommendations and no documentation showing the physician and responsible party notification. During a review of Resident 41's "Progress Note (PN)" dated 6/12/25, the PN indicated, "...Dietary: 6/1:160 lb, 5.3% 9 lb weight loss x 1 month (5/1:169lb) and 10.6% 19 lb weight loss x 6 months (12/1: 179lb) ..." There were no supplement recommendations and no documentation showing the physician and responsible party notification. During a review of Resident 41's "Progress Note (PN)" dated 7/15/25, the PN indicated, "...Dietary: 7/14:151lb, 2 lb weight loss x1 week (7/7:153lb) and significant 10.7% 18 lb weight loss x 2 months (5/1:169lb) ...IDT recommendation: continue with plan of care and monitor weekly weight x 1 week. Add [brand name of protein supplement] 30 ml bid [twice a day ] ..." There was no documentation indicating the physician was notified. During a review of Resident 41's "Progress Note (PN)" dated 7/21/25, the PN indicated, "New order received from MD [Name of MD] for [brand name of protein supplement] 30ml BID for supplement. Called R/P [name of R/P] son to notify him of new order..." During a review of the facility's policy and procedure (P&P) titled, "Weight Assessment and Intervention" undated, the P&P indicated, "...Weights are monitor monthly and more often as recommended by the interdisciplinary care team...Intervention...g. Use of supplementation..." During a review of the facility's policy and procedure (P&P) titled, "Weight Management Policy" dated 12/19/2022, the P&P indicated, "...Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight...6.Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days). B. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days) ... 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions..." During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ titled, "An approach to the management of unintentional weight loss in elderly people," dated March 15, 2005, the article indicated, "...Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period ...Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred ...Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both..." During a review of a professional references titled "Nutrition Care of the Older Adult" from the Academy of Nutrition and Dietetics, dated 2016, the article indicated, "...The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight..." During a review of a professional references retrieved from the Academy of Nutrition and Dietetics titled "What Resources Are Available to Assist in Assessing Body Weight in Older Adults" dated 7/1/2025 the article indicated, "...Usual body weight (UBW), an individual's weight throughout adult life or a stable weight over time, is the preferred standard for older adults. Any recent weight changes, especially unintentional weight loss, would also need to be addressed in a care plan. UBW is considered more appropriate than desirable body weight or ideal body weight for weight-related interventions in older adults..." In violation of the above cited standards, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 19 sampled residents (Resident 41), when Resident 41 experienced an unplanned weight loss of six pounds (3.4%) in one month (2/1/25-3/1/25), nine pounds (5.3%) in one month (5/1/25-6/1/25), and 23 pounds (13.7%) in five months (2/1/25 - 7/7/25), and interventions to prevent weight loss were not recommended and implemented in a timely manner. In addition, nursing staff did not notify the physician, notify Resident 41's responsible party (RP), schedule an inter-disciplinary team (IDT-a group of professionals from different fields who collaborate to achieve a common goal) meeting to determine the cause of the weight loss in accordance with professional standards of practice and the facility's policy and procedure, "Weight Management Policy " These failures had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), loss of independence, and decreased quality of life. The facility failed to 4. Implement interventions to prevent weight loss were not recommended and implemented in a timely manner. 5. Notify the physician, Resident 41's responsible party (RP), schedule an inter-disciplinary team (IDT-a group of professionals from different fields who collaborate to achieve a common goal) meeting to determine the cause of the weight loss in accordance with professional standards of practice 6. The facility failed to follow and the facility's policy and procedure, "Weight Management Policy " These failures had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable