Health inspection·June 11, 2025

§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. 72311(a)(1)(3)(D) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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. The following reflects the findings of the California Department of Public Health during the investigation of: Survey Re-licensing 8L2P11/Re-certification) Event ID: IK8O11 Representing the Department, HFEN #49330 State Citation B was written. On 4/7/25 at 7:30 A.M., an unannounced visit was conducted at the facility for a concurrent recertification and relicensing survey. The facility failed to implement a comprehensive systemic approach, to ensure nutritional status was maintained for Resident 12 when Resident 12's unplanned, significant weight loss (loss of body weight greater than 5% in a month) was not identified and addressed. As a result, the facility's system was not effective at identifying and addressing progressive weight loss. The staff were not consistent in identifying unplanned weight loss and significant weight loss. The interdisciplinary team (IDT - a group of professionals from different disciplines who collaborate to treat a patient's needs) did not develop a plan to monitor and address the resident's weight loss. 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) During a record review conducted on 4/7/25, the Admission Record indicated Resident12 was admitted to the facility on 9/14/12 and readmitted on 7/11/22 with diagnoses which included metabolic disorder (occurs when abnormal chemical reactions in your body disrupt this process), iron deficiency (a condition in which blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues), paraplegia (loss of motor and/or sensory function in the lower part of the body, including the legs and lower abdomen), and gastrostomy status (an opening (gastrostomy) into the stomach, typically for feeding or draining purposes). During a review of the Minimum Data Set (MDS-an assessment tool) dated 1/25/25, the MDS indicated, Resident 12 had a BIMS (Brief Interview for Mental Status - a tool to test cognition) score of 9 which meant a score between 8 and 12 indicated moderate to mild mental impairment. The MDS also indicated Resident 12 required substantial/maximal assistance with eating. On 4/7/25 at 12:23 P.M., an observation was conducted during lunch. Resident 12 was observed in the dining room. Certified Nursing Assistant (CNA) 1 was feeding Resident 12. CNA 1 was observed holding a spoon of pureed food up to Resident 12's mouth. Resident 12 had her lips tightly closed shut, and she tilted her chin away from the spoon. On 4/8/25 at 7:13 A.M., a concurrent observation and interview was conducted in the dining room during breakfast with Licensed Vocational Nurse Student (LVNS) 1. Residents were observed walking out of the dining room. Resident 12 was sitting in a wheelchair, at a dining room table during breakfast, without a breakfast tray. LVNS 1 stated Resident 12 refused to eat breakfast, and her tray was taken away. LVNS 1 stated, "...they're looking for something else to give her for breakfast..." LVNS 1 stated Resident 12 has been refusing to eat meals and, "...we give her [a supplemental drink] as alternative..." On 4/09/25 at 3:00 P.M., an interview was conducted with CNA 2. CNA 2 stated Resident 12 had been refusing to eat during meals. CNA 2 stated she noticed Resident 12 was losing weight. CNA 2 stated, "...Before when I would change her [briefs], it would be more difficult to put [the brief] around her...I think she uses the green [brief] which is size 2x. Now, the brief fits looser, we don't struggle as much to put it on her. That's how I could tell that she lost weight ..." During a review of Resident 12's Electronic Health Record titled "Weight Summary" for August 2024 through March 2025 indicated: 8/15/24-190.4 pounds 9/12/24-182 pounds 10/11/24-173 pounds 11/22/24-171.7 pounds 12/12/24- 168 pounds 1/15/25- refused to be weighed 2/12/25-164 pounds 3/14/25-157 pounds Resident 12 experienced a 25-pound weight loss (13.7%) in six months, from 9/24 to 3/25. During a review of Resident 12's Progress Notes, a note titled "Weight Change Note" dated 3/26/25 indicated, "Weight loss of 7 lbs (pounds) in the past 1 month reported to RD. Resident 12 was reported to be eating well. Good appetite and good p.o. (oral) intake. BMI (Body Mass Index - a widely used measure that estimates body fat based on height and weight) of 30. No diet changes recommended at this time. Continue monitoring daily p.o. intake and monthly weights. Notify RD of significant changes..." During a telephone interview with the Registered Dietitian (RD) on 04/08/25 02:19 P.M., the RD stated she was aware that Resident 12 had lost 7 pounds from 2/25 to 3/25. The RD stated the weight loss was unplanned and considered a significant weight loss. The RD stated in her opinion Resident 12's weight loss was not concerning because staff had reported that Resident 12 "...had been eating good..." and because Resident 12 was still in the "obese category" based on her height and weight. The RD stated, "I feel like I'm more concerned [about weight loss] with someone who is not eating..." The RD stated on 3/26/25 she wrote a progress note on 3/26/25, but did not do a comprehensive nutritional assessment for Resident 12. The RD stated comprehensive nutritional assessments were only done annually for all residents, regardless of any significant weight changes. The RD stated a comprehensive nutritional assessment should have been done for Resident 12 During a review of Resident 12's Weight Change Note dated 4/9/25 at 10:17 P.M., the note indicated, "Note for malnutrition risk s/p significant weight loss. [Resident 12] has had a weight loss of 28 lbs in the past year (from 185 lbs in March of 2024 to 157 lbs in March of 2025). This is a significant weight loss of 15%. Resident at risk for malnutrition. Weight loss has been gradual but significant month by month...Current BMI of 30 (obese). However, further weight loss should be avoided to prevent additional loss of muscle mass and to maintain mobility and strength..." During a review of Resident 12's Weight Summary dated, 4/10/25 at 8:58 A.M., Resident 12's weight was recorded as 147.4 pounds, which indicated a weight loss of 10 pounds (6%, which is a significant weight loss) since 3/14/25. On 4/10/25 at 11:09 A.M., a follow up interview was conducted with the RD. The RD stated she wrote a progress note on 4/9/25 with interventions to address Resident 12's weight loss. The RD stated, "...the interventions listed in the progress note [dated 4/9/25 at 10:17 P.M.] was what I should have done to prevent even more weight loss from happening..." On 4/10/25 at 8:20 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation that a comprehensive nutritional assessment was done when a resident has significant weight loss. The DON stated, "A comprehensive assessment should have been done, with interventions..." The DON stated the resident was, "...at risk of losing body mass, muscle mass, and losing function..." During a review of the facility policy titled Nutrition revised 10/17 indicated, "... 1. 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..." During a review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol revised 9/2012, the document indicated, "The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications..." In violation of the above cited standards, the facility failed to implement a comprehensive systemic approach, to ensure nutritional status was maintained for Resident 12. The above cited system failures had the potential to negatively impact and compromise Resident 12's medical status.