Other·March 30, 2026

State Citation A was written. CFR 483.25(g)(1)-(2) Assisted Nutrition and Hydration §483.25(g) Assisted nutrition and hydration. (Includes 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; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; 22 CCR § 72315 - Nursing Service-Patient Care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. 22 CCR § 72311 § 72311. Nursing Service-General. (a) Nursing service 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. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72523 § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. A Recertification Survey of the facility was conducted on February 24 through February 27, 2026. A resident with significant weight loss was identified during the survey. The facility failed to: 1. Implement nutritional interventions to address Resident 116's significant weight loss. 2. Plan, develop, implement, and update Resident 116's nutritional care plan based on Resident 1's health conditions, observed poor food intake, and significant weight loss. 3. Implement their policy and procedure related to weight management such as placing a resident on weekly weights, interdisciplinary (IDT) oversight, and identifying cause of weight concerns and implementing interventions. These failures resulted in a significant decline in Resident 116's weight from 141.8 pounds (lbs.) in December 2025 to 112.6 lbs. by February 2026. Unintentional weight loss in people older than 65 years is associated with increased morbidity and mortality. (American Family Physician, July 2021/Volume 104, Number 1) Resident 116 was admitted to the facility on 7/24/25 with a diagnosis of dysphagia (difficulty swallowing) and major depression per the facility admission record. Facility weight records indicated Resident 116 weighed 153.8 pounds (lbs.) on 7/27/25. The nutritional risk assessment (NRA), dated 7/31/25, indicated a goal weight range (GWR) of 145 to 165 lbs. and recommended a regular diet with mechanical soft texture and standard portions. Facility weight records indicated Resident 116 weighed 156.4 lbs. on 9/1/25 and 148.8lbs on 10/6/25. The NRA, dated 10/9/25, indicated registered dietitian (RD) 1 reviewed Resident 116's recent weight measurements and identified a 7.6 lb. weight loss over approximately one month, calculated as 4.9% of the resident's body weight. The RD noted the weight loss was just below the 5 percent threshold for significant weight loss and was potentially related to inadequate energy intake. The RD recommended increasing the meal portion size to large to prevent further fluctuation. The NRA did not recommend initiating weekly weights. Physician's orders, active as of 12/1/25, indicated Resident 116's order had been updated to minced and moist, but the portion size remained a regular standard portion. Facility weight records indicated Resident 116 weighed 141.8 lbs. on 12/1/25. The change of condition (COC) report, dated 12/5/25, indicated licensed nurse (LN) 3 documented Resident 116 experienced significant weight loss of 14.6 lbs. over the previous three months. A record review indicated the facility did not complete a NRA for Resident 116 in November 2025 or December 2025. Resident 116's Nutrition - Amount Eaten flow sheet for December 2025 indicated staff did not document intake for 16 meals and documented less than 50% intake for 38 meals. Physician's orders, active as of 1/1/26, indicated Resident 116 continued to have an active diet order of minced and moist with standard portion size. Facility weight records indicated Resident 116 weighed 127.2 lbs. on 1/6/26. The NRA, dated 1/13/26, indicated RD 1 reviewed Resident 116's weight history and documented continued weight decline as follows: 1. One month weight loss: 127.2 lbs. on 1/6/26 compared to 141.8 lbs. on 12/1/25 (-10.3% weight loss). 2. Three-month weight loss: 127.2 lbs. on 1/6/26 compared to 148.8 lbs. on 10/13/25 (14.5% weight loss). 3. Six-month weight loss: 127.2 lbs. on 1/6/26 compared to 153.8 lbs. on 7/27/25 (17.3% weight loss). RD 1 documented the continued weight loss was likely due to inadequate intake related to decreased ability to consume sufficient energy. The RD noted Resident 116 was no longer attending meals in the dining room and there was a noticeable decrease in intake. The RD documented Resident 116 would benefit from assistance and encouragement with meals. The RD recommended one magic cup daily at lunch and a fortified diet. The NRA did not recommend starting weekly weights. Resident 116's Nutrition - Amount Eaten flow sheet for January 2026 indicated staff did not document intake for nine meals, 50 meals were documented with less than 50 percent of the meal consumed, and two meals were documented as refused. Physician's orders, active as of 2/1/26, indicated there were no orders for weekly weights. Facility weight records indicated Resident 116 weighed 119.4 lbs. on 2/2/26. The NRA, dated 2/5/26, indicated the RD 1 reviewed Resident 116's last weight of 119.4 lbs. on 2/2/26 and recommended weekly weights be implemented. Facility weight records indicated the next documented weight of 112.6 lbs. was obtained on 2/19/26. Interdisciplinary team (IDT) meeting notes indicated, the first documented IDT team meeting notes addressing Resident 116's weight loss occurred on 2/6/26. The care plan addressing Resident 116's nutritional status, initiated on 8/1/25, indicated the resident had a nutritional problem or potential nutritional problem related to multiple medical conditions including dysphagia and major depressive disorder (MDD). The care plan established goals for the resident to maintain oral intake at 75% of most meals and maintain weight within the goal weight range without unintended weight change. The care plan directed staff to weigh Resident 116 at the same time of day monthly and as needed (PRN). The intervention for monthly weight monitoring was initiated on 10/20/25 and last revised on 10/23/25. The care plan directed staff to provide and serve the diet as ordered. This intervention was initiated on 10/20/25 and was not revised to reflect the fortified diet order until 2/24/26. The care plan did not include an intervention directing staff to monitor or document Resident 116's oral intake or provide staff assistance or supervision during meals. During an interview and record review on 2/24/26 at 11:17 A.M., Certified Nursing Assistant (CNA) 1 stated she was assigned to care for Resident 116. CNA 1 stated the facility did not have dedicated feeding assistants and that CNAs or restorative nursing assistants (RNAs) supervised and assisted residents with meals as needed. Review of the daily assignment sheet with CNA 1 indicated Resident 116 was not listed as requiring feeding assistance. CNA 1 stated Resident 116 did not eat much of her breakfast that day. Resident 116's Nutrition - Amount Eaten flow sheet entry for 8 A.M. on 2/24/26 indicated CNA 1 documented Resident 116 ate 0-25% of the breakfast meal. During an observation on 2/24/26 at 1:03 P.M., Resident 116 was lying in bed with a lunch tray placed in front of her. The meal on her plate appeared partially eaten with only a few bites consumed. No staff were observed in the room assisting Resident 116 with the meal at the time of the observation. Resident 116's Nutrition - Amount Eaten flow sheet entry for 12 PM on 2/24/26 indicated CNA 1 documented Resident 116 ate 0-25% of the lunch meal. The Nutrition - Amount Eaten flow sheet indicated staff did not document meal intake entries for 8 A.M. and 12 P.M. on 2/25/26. During an interview on 02/26/2026 at 12:05 PM Resident 116 stated she had eaten a little of her breakfast meal that morning but did not provide additional information regarding her food intake. During an interview on 2/26/26 at 12:12 PM, CNA 2 stated Resident 116 did not eat much and had just been placed on the feeding assistant list that day. CNA 2 stated staff were required to document the percentage of food consumed for every meal in the electronic health record. CNA 2 stated Resident 116 had eaten about 25% of her breakfast. During an interview on 2/26/26 at 4:30 P.M., licensed nurse (LN) 1 stated she was serving as the charge nurse and familiar with Resident 116's care. LN 1 stated Resident 116 did not have problems eating and was not on the list of residents requiring supervised or assisted eating. During an observation and interview on 2/27/26 at 9:39 A.M., CNA 3 stated CNAs are required to chart amount of each meal eaten in the EHR. CNA 3 demonstrated how to enter meal percentage eaten into the EHR. CNA 3 stated if a resident continues to have below 50% meal intake the nurse should be notified. During an interview on 2/27/26 at 9:48 A.M., LN 2 stated CNAs are required to chart the percentage of each meal eaten in nutritional task in the EHR and notify the nurse of any refused meals. LN 2 stated it is important CNA's chart every meal to make sure the facility stays on top of residents at risk for weight loss. LN 2 stated if a Resident ate less than 25% of any meal the nurse should be notified to ensure weight is monitored. During an interview and record review on 2/27/26 at 9:58 A.M., Registered Dietician (RD) 2 stated residents with weight variances should be discussed in weekly interdisciplinary team (IDT) weight meetings and that Certified Nursing Assistants (CNAs) were expected to document the percentage of food consumed for each meal in the EHR flowsheet for nutrition intake. RD 2 stated oral intake documentation and resident weights were objective measures used to evaluate nutritional status and determine the need for dietary interventions. RD 2 stated significant weight loss was defined as 5% loss in one month, 7.5% loss in three months, and 10 percent loss in six months. RD 2 stated if significant weight loss was identified it should trigger weekly weight monitoring and an IDT review. During a review of Resident 116's NRAs, intake documentation, and weight records, RD 2 stated nursing documented a change of condition for significant weight loss on 12/5/25 but a nutritional assessment was not completed until a month later on 1/6/26. RD2 acknowledged meal intake documentation contained multiple entries of less than 50% intake and had multiple missing entries. RD 2 acknowledged an NRA should have been completed following the identification of a significant weight loss. RD 2 stated weekly weight monitoring should have been initiated when the significant weight loss was first identified, and acknowledged weekly weights were not recommended until the NRA on 2/5/26 and were not obtained until two weeks later on 2/19/26. RD 2 stated when staff did not document meal intake the facility could not determine whether nutritional interventions were effective. RD 2 stated weekly weight monitoring and meal intake documentation were important data to identify continued weight loss and implement timely interventions. During an interview and record review on 2/27/26 at 2:06 P.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated residents were weighed monthly and that weight variances of 5% or 5 lbs loss in one month, 7.5% loss in three months, 10% loss in six months, or a 2% loss in one week required nursing to complete a COC report and notify the RD. The DON and ADON stated CNAs were required to document the percentage of food consumed for each meal in the EHR flow sheets and report meals with intake below 50% to the nurse. The DON and ADON stated nursing should review intake documentation and follow up when intake was low or documentation was missing. The DON and ADON further stated significant weight loss should trigger weekly weight monitoring, weekly IDT weight meetings, and care plans should be updated based on interventions discussed during IDT review. During the record review of Resident 116's chart, the DON stated the significant weight loss documented in the nurses COC on 12/5/26 should have triggered weekly weight monitoring. The DON further stated the continued significant weight loss identified on 1/6/26 in the NRA should also have triggered weekly weights, an IDT review, and updated care plan interventions reflecting IDT recommendations. A review of the facility policy, titled, "Evaluation of Weight and Nutritional Status," revised 1/30/25, indicated, "...Policy: 1. The facility will maintain an acceptable nutritional status for residents per professional standards by:... b. Analyzing the assessment information to identify the medical conditions, causes and/or problems... c. Implementing interventions for maintaining or improving nutritional status... e. Monitoring and evaluating the resident's response, or lack of response to interventions... Clinical Evaluation:... b. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days... will be evaluated by the IDT to determine the cause of the weight loss/gain and the interventions required... Once weight gain or loss as describe above is identified, the IDT will: 1. Identify and implement appropriate interventions; 2. Update and revise the Care Plan... d. Any resident meeting the criteria for physician prescribed weight loss and any resident at risk for weight loss or gain will be weighed and documented weekly. Weekly weights will be reviewed by the IDT... Resident's at risk who should be weighed weekly include... 2. Significant weight loss or gain identified in a 30, 90, 180-day period. .. Monthly evaluation will continue for all residents." The facility failed to: 1. Implement nutritional interventions to address Resident 116's significant weight loss. 2. Plan, develop, implement, and update Resident 116's nutritional care plan based on Resident 1's health conditions, observed poor food intake, and significant weight loss. 3. Implement their policy and procedure related to weight management such as placing a resident on weekly weights, interdisciplinary (IDT) oversight, and identifying cause of weight concerns and implementing interventions. These failures resulted in a significant decline in Resident 116's weight from 141.8 pounds (lbs.) in December 2025 to 112.6 lbs. by February 2026. Unintentional weight loss in people older than 65 years is associated with increased morbidity and mortality. (American Family Physician, July 2021/Volume 104, Number 1) These violations, jointly or separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.