Health inspection·September 5, 2025

The following reflects the findings of the California Department of Public Health during the investigation of annual recertification survey conducted at the facility from 8/5/2025-8/8/2025 State B Citation was written. 42 CFR §483.25 (g) (1) The facility must: (1) Maintain 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. 22 CCR §72311 Nursing Services (a) shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (D) Change in weight of five pounds or more withing 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. 22 CCR §: 72315(h) Nursing Services- Patient Care. Patients in a skilled nursing facility receive good nutrition and necessary fluids for proper hydration. The facility failed to implement a comprehensive systematic nutritional approach to prevent weight loss for 1 of 5 sampled Residents (Resident 3) when: 1. The facility did not follow their policy for change of condition (physical change-weight loss) when Resident 3 was not placed on weekly weights (measurement of body weight). 2. The Registered Dietitian (RD) did not reassess Resident 3's weight loss to determine appropriate interventions. 3. Resident 3's weight loss was not communicated to the physician. 4. The Interdisciplinary Team (IDT- a team comprised of professionals from various disciplines who work in collaboration to address residents' needs) did not address the severe unplanned weight loss. 5. Resident 3's care plan did not reflect the severe unplanned weight loss, and no interventions (an action taken to address Resident 3's weight loss) were implemented. As a result, Resident 3 experienced a total of 24.4 lbs. (pounds- a measurement of weight), 14.77% unplanned weight loss from 4/5/25 to 8/6/25. Resident 3 was at risk to experience medical complications including but not limited to dehydration, loss of muscle mass with decreased mobility, and negatively affect Resident 3's health and well-being, which could include death. Findings: A record review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on 4/4/25 with diagnoses which included type 2 diabetes (a condition in which the body has trouble controlling blood sugar and using it for energy), functional quadriplegia (the inability to move all four limbs due to severe disability or weakness), gastro-esophageal reflux disease (a condition in which stomach contents move up into the esophagus), and a history of falling. A record review of Resident 3's Minimum Data Set (MDS- a standardized comprehensive assessment of residents' health conditions, functional abilities, and care needs) report dated 7/9/25 indicated the resident's brief interview of mental status (BIMS- a cognitive screening test) score was 15, which indicated intact cognition. On 8/5/25 at 8:50 A.M., a joint observation and interview was conducted with Resident 3 in his room. Resident 3 was in bed and had his breakfast tray in front of him. Resident 3 had eaten most of his breakfast. Resident 3 stated he liked breakfast, but lunch and dinner were "...hit or miss. I'll ask for a sandwich if I don't like the food..." Resident 3 stated, "I didn't care for the food the last couple of weeks..." and that he had recently lost weight. Resident 3 stated he received a [Nutrition Shake] (meal or snack replacement designed for diabetic patients) with every meal. Resident 3 stated he consumed the entire bottle of the nutritional supplement during breakfast. Resident 3 stated he rarely consumed the full amount of the nutritional shake for lunch and dinner, "...sometimes I drink a third, sometimes half, sometimes less. It depends on..." Resident 3 stated he weighed "about 170 pounds" prior to admission to the facility, and now weighed "about 140 lbs." Resident 3 stated he would not like to lose any more weight because he did not want his clothes to fit too loosely. Resident 3 stated he did not know the reason he had lost weight, and he had not planned to lose weight. On 8/5/25 at 8:59 A.M., an interview was conducted with Resident 77 (Resident 3's wife and current roommate). Resident 77. Resident 77 stated that Resident 3 would often choose food options from an alternative menu. Resident 77 stated, "...my husband is losing weight. He tries to give me his chips sometimes and I tell him he needs to eat it, so he doesn't lose anymore weight..." A record review of Resident 3's Weight Summary dated 8/6/25 indicated: 4/5/25 165.2 lbs. (pounds-measurement of weight). 5/4/25 153.6 lbs. 5/10/25 150.6 lbs. 5/22/25 147.2 lbs. 6/2/25 146.6 lbs. 6/19/25 147.6 lbs. 7/1/25 148.1 lbs. 8/1/25 140.0 lbs. 8/6/25 140.8 lbs. Resident 3 experienced a 17.1 lb., 10.35% severe weight loss in ninety days or 3 months, from 4/5/25 to 7/1/25. On 8/6/25 a record review of Resident 3's Nutrition Evaluation dated 4/7/25 was conducted. The Nutrition Evaluation was completed by the Registered Dietitian and indicated Resident 3's usual body weight was between 170-175 lbs. The Nutrition Evaluation indicated Resident 3 was not on a planned weight change program. The Nutrition Evaluation further indicated, "...Seen during lunch, reports poor intake x 1.5 weeks...Goal to remain weight stable through recovery. Mod [moderate] nutrition risk per poor intake, recent wt. [weight] loss...Nutrition Monitoring: Monitor intake, weight, evaluate labs when available. Will adjust nutrition POC [Plan of Care] as indicated..." On 8/6/25 a record review of Resident 3's Nutrition Evaluation dated 7/7/25 was conducted. Per the Nutrition Evaluation document... "Describe any recent weight changes...currently weight stable x 2 months weight loss -17.1# (10.4%) over the first month of admission 3 months ago... [Resident 3] is at potential risk for weight loss, dehydration, and malnutrition r/t [related to] variable PO [oral-by mouth] intake and recent wt. [weight] loss trend." There were no new interventions or recommendations indicated in the Nutrition Evaluation. LN 3 and RD verified there was no documentation related to interventions for Resident 3's weight loss. On 8/6/25 at 12:52 P.M., an interview was conducted with the Restorative Nursing Assistant 1 (RNA-Certified Nurse Assistant who work alongside rehabilitation staff to provide exercises for residents with limited mobility). RNA 1 stated she was responsible for obtaining residents' weights. RNA 1 stated newly admitted residents were weighed the day after admission, then once a week for the first four weeks. RNA 1 stated a list of any significant weight changes were provided to the Director of Nursing (DON) and/or the charge nurse. RNA 1 stated, "...the Registered Dietitian (RD) doesn't need a copy of the weights because she can read it in [the Electronic Health Record]." RNA 1 stated she had not attended any IDT weight meetings. RNA 1 stated she was aware that Resident 3 had been losing weight and had been refusing RNA exercises because Resident 3 was "too tired." On 8/7/25 at 9:56 A.M., a joint interview and record review of Resident 3's facility chart was conducted with Licensed Nurse (LN) 3. LN 3 stated, "A significant weight loss is considered a change of condition (COC) because [the weight loss] is not normal for the patient, if [the weight loss] was not planned we need to figure out why it's happening and to implement new interventions to take care of the resident." LN 3 stated there was not a COC completed to address Resident 3's weight loss and to notify the physician. LN 3 stated, I did not see a COC in Resident 3's EHR (electronic health record). LN 3 stated Resident 3's care plan should have been updated to reflect the weight loss. LN 3 further stated [Nutritional shake] was not listed in Resident 3's Physician's Orders, and there was no documentation of the amount of the nutritional shake consumed. LN 3 stated it was important to document the amount of [Nutritional shake] consumed by Resident 3 to ensure he was receiving enough calories. On 8/7/25 at 2:12 P.M., a joint interview and review of Resident 3's facility medical record was conducted with the Dietary Manager (DM) 1. DM 1 stated she was responsible for obtaining residents' food preferences upon admission, and updated preferences when there were changes in the residents' condition, such as weight loss. DM 1 stated Resident 3 usually asked for a sandwich for lunch, instead of the standard menu items. DM 1 stated Resident 3 typically ate lunch in the dining room, but lately he had been eating in his room. DM 1 stated "I noticed [Resident 3] is only eating half of his sandwiches for lunch. DM 1 stated currently he gets [Nutritional shake] three times a day." DM 1 stated she was not sure if Resident 3 was consuming all of the [Nutritional shake] because there was no recording of the amount of the [Nutritional shake] consumed by Resident 3. DM 1 stated she knew Resident 3 should have had a nutritional shake because the RD had recommended a nutritional shake. On 8/7/25 at 2:49 P.M., a telephone interview was conducted with the Registered Dietitian (RD). The RD stated it was important that residents were weighed weekly upon admission, "to see any significant trends...if there's pertinent wounds or conditions that require more calories or nutrition. It's critical to see the weight trend for that month...to give us a good foundation to see if they're eating enough..." The RD stated, "[Resident 3] wasn't trying to lose weight, but it was acceptable to him. The weight loss is not acceptable to me because it does impact his nutritional status and can lead to malnutrition, and to recover and stay well..." In addition, the RD stated, "[Resident 3] will be prone to muscle weakness and skin breakdown...gaining weight would improve his quality of life." The RD stated an IDT note to address Resident 3's weight loss should have been in Resident 3's medical records. On 8/8/25 at 1:04 P.M., a telephone interview was conducted with the Medical Director (MD). The MD stated his expectation was for any significant or severe weight loss to be addressed during the IDT meeting. The MD stated he expected weight loss interventions to be implemented. The MD stated, "We don't want [Resident 3] to decline, have skin breakdown...a lot of things could happen for this resident such as major physical decline due to weight loss and this could have been easily addressed." During a record review on 8/8/25 the facility's policy titled Weight Management revised 10/24, the policy indicated, "Significant weight changes (>/=2% in one week or >/=5% in one month) must be noted on the weekly report forms and reported to the attending physician by the licensed nurse...Residents who have been deemed as having significant weight loss or gain will be assessed by the Registered Dietitian for dietary changes and recommendations...The attending physician will be informed of all significant weight loss and gain." During a record review on 8/8/25 of the facility's policy titled Nutritional Assessment revised 10/17, the policy indicated, "The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission...and as indicated by a change in condition that places the resident at risk for impaired nutrition...Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications..." During a record review on 8/8/25 of the facility's policy titled Weight Assessment and Intervention revised 3/22, the policy indicated, "The threshold for significant unplanned and undesired weight loss will be based on the following criteria:...1 month- 5% weight loss is significant; greater than 5% is severe...3 months- 7.5% weight loss is significant; greater than 7.5% is severe...6 months- 10% weight loss is significant; greater than 10% is severe..." According to a 2002 American Academy of Family Physicians Journal article, "Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, (the ability for the body to develop an immune response) depression and an increased rate of disease complications. Research has shown institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year." (www.aafp.org/afp) According to a literature review of the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, " ...Unintended weight loss is linked to increased mortality (death) among older adults ... residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death..." (https://www.nutritioncaremanual.org/). The above violations either jointly, separately, or in any combination had a direct or immediate relationship to health, safety or security of residents.