Health inspection·December 24, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform the weekly weights for one of the four sampled residents (Resident 1) per order and care plan. This failure exacerbated Resident 1's weight loss significantly.Findings:During a review of Resident 1's admission Record (AR), AR indicated, Resident 1 was admitted on [DATE] with diagnoses which included Metabolic encephalopathy (when the brain does not work because of chemical imbalance or problem in the body's metabolism), Burn of Second Degree of Left Thigh due to heatstroke (heatstroke- when the body overheats dangerously from too much sun, leading to symptoms like confusion, dizziness, high fever, requiring immediate medical help.)During a review of Nutritional Risk Assessment (NRA), dated and signed by Registered Dietician (RD) on 7/8/25, the NRA indicated, .Goals: Maintain weight within +/- 5 pounds of current body weight (CBW). Resident 1's admission weight was 198 lbs. (pounds- a unit of weight measurement).During a review of order summary report (OSR) dated 7/2/25 indicated, Weekly Weights x 4 Weeks every dayshift every 7 day(s) for 4 Weeks.During a review of Resident 1's Care Plan (CP) initiated on 7/4/25, the CP indicated, .potential nutritional problem related to Metabolic Encephalopathy, Burn of Second degree, Heat Stroke with interventions which indicated, .weekly weights x 4 weeks and then monthly if stableDuring a review of Resident 1's average meal intake for the month of 7/25 indicated, the amount eaten for breakfast was 26-50%, Lunch 26-50%, Dinner 51-75%. No evidence in the progress notes that the licensed nurses were notified when his meal intakes were 26-50%. No evidence in the progress notes that licensed nurses were notified when he refused his meals.A review of Resident 1's weight logs indicated, 7/2/25 198 lbs. (admission weight) 7/7/25 190.5 lbs. 7/14/25 No documented weight 7/25/25 173.5 lbs. (18 days since his last weight recorded) 8/2/25 170 lbs.(8 days since last weight was recorded) 8/11/25 165.5 lbs. (9 days since last weight was recorded)An interview with Licensed Nurse (LN)1 on 12/24/25 at 10:10 a.m., stated, newly admitted residents will be weighed within twenty-four hours. LN 1 further stated weekly weights for four weeks and then monthly. During an interview on 12/24/25 at 12:23 p.m. with Registered Dietician (RD), RD stated, resident was weighed upon admission, then weekly for four weeks, then monthly.During an interview on 12/24/25 at 1 p.m. with the Director of Nursing (DON), the DON stated, her expectations were for the staff to follow doctor's orders, follow the care plan, and to notify the licensed nurse when there were changes with their resident's condition or if the meal intake was poor. DON further stated, the certified nurse assistant (CNA) uses the Tasks tab in the electronic medical record (EMR) to document and report the amount eaten for breakfast, lunch, and dinner. DON further stated, if there were any concerns or changes in condition, the CNAs must flag (to mark for attention) and report those concerns through the tasks tab related to the resident through the EMR, or they can verbally addressed the concerns to the licensed nurses. DON further stated, they do not have any policy related to the communication process of CNAs to their LNs related to change of condition or concerns.During a telephone interview on 12/26/25 at 3:27 p.m. with Director of Residents Affected - Few Page 1 of 2 055014 055014 12/24/2025 Fairfield Post-Acute Rehab 1255 Travis Blvd Fairfield, CA 94533

F 0684 Level of Harm - Minimal harm or potential for actual harm Nursing (DON), DON stated, there was no documentation of weight on 7/14/24. No follow-up documentation was provided related to the missed weight on 7/14/25. During a review of facility's policy and procedure titled, Clinical Practice Guidelines, revised, 2/25, indicated, .each resident is to be weighed within 24 hours of admission, weighed weekly for four weeks upon admission. Residents Affected - Few 055014 Page 2 of 2