Health inspection·August 11, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. 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 provide appropriate services to one of three sampled residents (Resident 1) when the Registered Dietitian (RD) did not reevaluate and address Resident 1's severe weight loss (a weight loss greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months).This failure placed Resident 1 at risk for decline in nutritional status and physical health.Resident 1 was admitted on [DATE] with diagnoses that include left distal radius fracture (a break of the bone near the wrist of the left forearm) and cerebral palsy (a condition that affects a person's ability to move and maintain balance and posture). Resident 1 was transferred to acute care hospital on 7/2/25 and was discharged from the facility on 7/9/25.Review of Resident 1's weight record indicated an initial weight of 230 pounds on 5/23/25.During a review of Resident 1's Registered Dietitian Nutrition Assessment (RDNA), dated 5/21/25, the RDNA indicated Resident 1's hospital weight on 5/13/25 was 249.6 pounds. The RDNA showed Resident 1's BMI score (body mass index, a measure of body fat based on a person's height and weight) as 32.1 indicating obesity (having excessive body fat). Further review of the RDNA indicated Evaluation. He (Resident 1) endorsed having a fair appetite. He is fine with current portion sizes. He did not want snacks/supplements at this time. RD educated resident on the importance of eating to maintain strength.Interventions and Plan: Consider re-visiting snack/supplements if rt (resident) has weight loss. F/U (follow up) PRN (as needed).During a review of Resident 1's RD Medical Nutrition Therapy Note (RD Note), dated 5/28/25, the RD Note showed Resident 1's weight as 230 pounds on 5/23/25 and 227 pounds on 5/28/25. The RD Note indicated Resident 1 has a weight loss of 1.3% pounds in one week. The RD Note also indicated Resident is reviewed for inadequate intake. Resident's intake remains fair, however, calculated to meet estimated needs. Weight stable x (for) 1 (one) week with minor weight loss, may be related to swelling of fingers on admission. No edema noted at this time. No new labs (laboratory) to review. No new dietary interventions. Will continue to monitor and f/u (follow up) PRN (as needed).During a review of Resident 1's Progress Notes (PN), dated 6/19/25, the PN showed Resident 1's weight on 6/18/25 as 217 lbs., a 5.7% weight loss in in 26 days. The PN indicated Resident 1 eats 76% to 100% of his meals. The PN also indicated Weight loss of unknown etiology (cause). Beneficial for resident considering BMI now 29.4. During a review of Resident 1's PN, dated 6/26/25, the PN showed Resident 1's weight on 6/25/25 was 210.8 pounds, indicating an 8.3% weight loss in 33 days. The PN indicated Resident 1 eats 51% to 75% of his meals. The PN also indicated RD/IDT (Interdisciplinary Team) Recommendations: Weight loss of unknown etiology. Beneficial for resident considering BMI now 28.6. Continue to monitor.During a review of Resident 1's care plan (CP) titled, At Risk for Altered Nutrition Status R/T (related to) Malnourished as evidenced by Nutritional Screening Tool, created on 5/20/25 and last revised on 6/9/25, the CP included a goal of no significant weight change for 30 or 180 days. The CP interventions included monitor closely for weight gain/loss.During an interview on 8/11/25 at 11:33 AM, the RD stated, I did not really Residents Affected - Few Page 1 of 2 555827 555827 08/11/2025 Atherton Park Post-Acute 1275 Crane Street Menlo Park, CA 94025

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few know why he was losing weight; he was eating very well. The RD stated that part of her responsibility is to assess the cause of weight loss and if the resident is not eating well, to recommend nutritional supplements, if appropriate. The RD was asked if she reassessed Resident 1. The RD stated, I was not able to. I was not able to speak with the patient (Resident 1) if he wanted supplements. The RD added, We should be investigating why they (residents) lost weight. From there, we formulate interventions.During an interview on 8/11/25 at 12:36 PM, Resident 1's attending physician stated that Resident 1's weight loss was unintentional but it was desirable for him. if it continues, the nutritionist (RD) should take a look for any reason for this (weight loss), then we go from there.Review of the facility's policy tiled, Nutrition (Impaired)/Unplanned Weight Loss -Clinical Protocol, revised on 8/2017 indicated Monitoring - 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss.)Review of the facility document, titled JOB DESCRIPTION Registered Dietitian Nutritionist, last revised on 11/2017, indicated The Registered Dietitian Nutritionist provides nutritional analysis and guidance to individual residents to treat and prevent disease. They also work closely with the Dietary Department to maintain good nutritional standards and process improvement. ESSENTIAL JOB FUNCTIONS: Assesses the nutritional needs of residents.Provides resident with ongoing nutrition assessment and outcome-oriented nutrition counseling necessary to assist resident in achieving and sustaining an effective nutritional status.Identifies malnourished residents as well as residents at risk for malnutrition and works collaboratively with interdisciplinary team to identify appropriate interventions, resources or solutions. 555827 Page 2 of 2