Health inspection·January 15, 2026

42 CFR §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- (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. 22 CCR § 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. 22 CCR § 72315 Nursing Service-Patient Care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. 22 CCR § 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. On 11/20/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate allegations indicating Resident 1 was being neglected and had bedsores (localized, pressure-related damage to the skin and/or underlying tissue usually over bony prominence [any point of the body where the bone is immediately below the surface]). The facility failed to prevent Resident 1 from having unplanned severe (greater than 5 percent weight loss in one month) weight loss. The facility failed to: 1. Implement Resident 1’s Care Plan titled, “Has Potential for Nutrition Problems” which indicated to monitor and document Resident 1’s meal percentage consumed for each meal. 2. Implement Resident 1’s Care Plan titled, “Malnourished as evidenced by Nutritional Screening Tool Score of 02” which indicated to offer supplement to Resident 1 if his intake was below 50 percent. 3. Follow the Registered Dietician’s (RD) recommendations dated 7/14/2025 and 9/3/2025 to provide large-portion meals to Resident 1. 4. Conduct an Interdisciplinary Team ([IDT] group of healthcare professionals working together to plan the care needed for each resident) meeting to address Resident 1’s unplanned severe weight loss on 9/1/2025, make recommendations and Care Plan to prevent further weight loss. These failures resulted in Resident 1 having severe weight loss of 12.6 pounds (lbs.) from 8/4/2025 to 9/1/2025 (within 28 days) and 15 lbs. from 9/15/2025 to 9/23/2025 (within 8 days). Resident 1 was transferred to the General Acute Care Hospital (GACH) and underwent a Percutaneous Endoscopic Gastrostomy (PEG) tube ([PEG] a feeding tube that is inserted directly into the stomach for administering nutrition fluids for residents who have difficulty swallowing or cannot get enough nutrition by mouth) placement. Resident 1 was a 70-year-old male, who was initially admitted to the facility on 6/27/2025 and readmitted on 10/30/2025. Resident 1’s diagnoses included hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body) and hemiparesis (weakness on one side of the body affecting the arm and/or face) following cerebral infarction (loss of blood flow to a part of the brain) affecting the left non-dominant side, unspecified protein-calorie malnutrition (serious condition from not getting enough protein and calories, causing poor growth, weight loss, weakened immunity and organ dysfunction), and dysphagia (difficulty swallowing). A review of Resident 1’s Nutritional Evaluation dated 6/30/2025, indicated Resident 1 had a score of 0-7 points (reference range 12-14 points = normal nutritional status, 8-11 points = at risk of malnutrition, 0-7 points = malnourished [the body is not getting the right amount of nutrients or food essential for optimal health]). A review of Resident 1’s Care Plan titled, “Has potential for Nutrition Problems” dated 6/30/2025, indicated interventions for RD to evaluate and make diet change recommendations as needed (PRN). The Care Plan interventions indicated the facility will monitor and record the resident’s intake on each meal. A review of Resident 1’s Care Plan titled, “Malnourished as evidenced by Nutritional Screening Tool score of 02” dated 6/30/2025, indicated Resident 1 was at risk for increased susceptibility to infections, muscle wasting (loss of muscle tissue, making muscles smaller, weaker and less functional), weakness, chronic diseases, impaired wound healing, cognitive impairment, dehydration, constipation, weight loss, and low Body Mass Index ([BMI] a calculation that uses a person’s weight and height to estimate whether someone is at a healthy weight]). The Care Plan goal indicated Resident 1 would receive adequate nutrition and avoid weight loss as much as possible. The Care Plan interventions included to record meal percentage for every meal and offer supplement to Resident 1 if intake was below 50%. A review of Residents 1’s History and Physical (H&P) dated 7/2/2025 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS] a resident assessment tool) dated 7/4/2025, indicated Resident 1 had severe cognitive impairment (problems with the ability to think and reason). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform Activities of Daily Living (ADLs) such as eating and was dependent (helper does all the effort) for bed mobility (the ability to move in bed) such as rolling left and right and changing positions from sitting to lying. A review of Resident 1’s Nutritional Assessment dated 7/14/2025, indicated Resident 1 was visually assessed as being underweight and had low albumin (blood test used to check general health and nutrition) level of 3.3 grams per deciliter ([g/dl] unit of measurement, therapeutic range of 3.5- 5.7 g/dl). The Nutritional Assessment indicated Resident 1 was 145 lbs., with an ideal body weight (IBW) of 178 lbs. (32 lbs. under IBW) and a BMI of 19.9. Resident 1 was at risk for weight loss due to low BMI. The RD’s Nutritional Interventions and recommendations included providing a mechanical soft diet with large portions to Resident 1. A review of Resident 1’s Physician’s Orders for the months of 7/2025-8/2025, did not indicate Resident 1 had Physician’s orders for large portions during meals. A review of Resident 1’s Weight Summary dated 8/4/2025, indicated Resident 1 weighed 148.6 lbs. on 8/4/2025. A review of Resident 1’s Change of Condition (COC) dated 9/2/2025 indicated Resident 1 weighed 136 lbs. on 9/2/2025 (8.5% weight loss in one month compared to 8/4/2025). The COC indicated the physician recommended implementing weekly weights and refer to the RD. A review of the RD’s Nutritional/Dietary Note dated 9/3/2025, indicated Resident 1’s weight was 136 lbs., weight loss of 12.6 lbs. (8.5%) in one month and a BMI of 18.4. The Nutritional/Dietary Note indicated to provide large portions at meals for Resident 1. A review of Resident 1’s Physician’s Orders for the month of 9/2025, did not indicate Resident 1 had Physician’s orders for large portions during meals. A review of Resident 1’s ADL Meal Logs for the months of 8/2025 and 9/2025, did not indicate Resident 1’s intake percentages were recorded for the following meals: 8/2/2025 for breakfast and lunch  8/6/2025 for breakfast and lunch  8/9/2025 for breakfast and lunch  8/10/2025 for breakfast and lunch  8/17/2025 for breakfast and lunch  8/25/2025 for dinner  8/26/2025 for lunch  8/27/2025 for breakfast and lunch  8/28/2025 for dinner  8/29/2025 for dinner 8/30/2025 for breakfast and lunch  8/31/2025 for dinner   9/4/2025 for dinner  9/21/2025 for breakfast and lunch  The ADL Meal Log also indicated the following intake percentages for Resident 1:  0-25% on 8/20/2025, 9/11/2025, 9/15/2025- 9/16/2025, 9/18/2025- 9/19/2025, 9/22/2025- 9/23/2025 for breakfast, 9/15/2025, 9/18/2025, 9/22/2025- 9/23/2025 for lunch, and 9/5/2025, 9/13/2025-9/14/2025 for dinner. 26-50% on 8/2/2025, 8/8/2025, 8/10/2025, 8/13/2025, 9/15/2025- 9/16/2025, 9/22/2025 for dinner, 9/7/2025, 9/12/2025- 9/14/2025, 9/20/2025 for breakfast, and 9/12/2025 - 9/14/2025, 9/16/2025, 9/19/2025- 9/20/2025 for lunch.  A review of Resident 1’s “Nutrition- Nourishment” and Nurses Notes for the month of 8/2025 and 9/2025, did not indicate Resident 1 was provided supplement for intakes of less than 50% on 8/20/2025, 9/11/2025, 9/15/2025- 9/16/2025, 9/18/2025- 9/19/2025, 9/22/2025- 9/23/2025 for breakfast, 9/15/2025, 9/18/2025, 9/22/2025- 9/23/2025 for lunch, and 9/5/2025, 9/13/2025-9/14/2025 for dinner. A review of Resident 1’s active Care Plans for the month of 9/2025 did not indicate Resident 1’s actual and severe weight loss was addressed after it was identified on 9/1/2025. A review of Resident 1’s Weight Summaries dated 9/15/2025 and 9/23/2025 sequentially, indicated Resident 1 weighed 139.2 lbs. on 9/15/2025, and 128.6 lbs. on 9/23/2025 (a total weight loss of 15 lbs. [11.1%]) A review of Resident 1’s Nurse’ Note dated 9/24/2025, indicated the Physician ordered to transfer Resident 1 (on 9/24/2025) to the GACH due to Failure to Thrive (state of progressive decline, weight loss, poor nutrition and decreased appetite). A review of Resident 1’s GACH Physician’s Notes dated 9/24/2025, indicated Resident 1 had poor oral intake, unintentional weight loss and generalized weakness. The GACH notes indicated Resident 1 weighed 56 kilograms ([kg.] unit of measurement [123.2 lbs.]) and had a BMI of 16.9. The GACH notes indicated Resident 1 had diagnoses including Failure to Thrive and poor intake. During a review of Resident 1’s GACH Gastrointestinal (GI) Physician Progress Note dated 10/4/2025, indicated Resident 1’s Assessment and Plan included dysphagia, malnutrition, Failure to Thrive and underwent a PEG placement on 10/2/2025. During a concurrent interview and record review on 11/26/2025 at 9:09 a.m., with the RD, Resident 1’s RD evaluations and Progress Note dated 9/3/2025, were reviewed. The RD stated she was informed of Resident 1’s weight loss on 9/3/2025 and documented a recommendation for large portions of food for Resident 1. During a concurrent interview and record review on 11/26/2025 at 11:08 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 1’s ADL Meal Log for the month of 8/2025 was reviewed. LVN 3 stated that not all meal intakes were documented for the month of 8/2025. LVN 3 stated this should not happen especially because Resident 1 was at risk for poor nutrition. LVN 3 stated Resident 1 could have lost weight and not received enough nutrients. During a concurrent interview and record review on 11/26/2025 at 2:12 p.m., with Registered Nurse (RN) 2, the following Resident 1’s records were reviewed:  1. ADL Meal Log, for the month of 8/2025  2. Weights  3. Care plan titled, “Potential For Nutrition Problems,” dated 6/30/2025  4. Nutritional Assessment dated 7/14/2025 5. RD’s progress note, dated 9/3/2025  6. All active and discontinued diet orders for the months of 7/2025-9/2025.  RN 2 stated staff should have documented all of Resident 1’s meal intake to ensure Resident 1 did not lose weight. RN 2 also stated Resident 1’s Care Plan indicated to monitor the Resident’s meal consumption, but staff did not follow it. There should have been an order for large meal portions for Resident 1 per RD’s recommendations on 7/14/2025 and 9/3/2025 but it was not followed through with the physician. There were no new orders for large meal portions after 7/14/2025 and 9/3/2025. During concurrent interviews and record reviews on 11/26/2025 at 4:07 p.m. and 12/11/2025 at 2:54 p.m., with the Director of Nursing (DON), the facility’s P&P titled, “Assessment and Management of Resident Weights,” dated 5/1/2018 and the following Resident 1 records were reviewed:  1. ADL Meal Logs, for the months of 8/2025 and 9/2025 2. Weights  3. Care plans titled, “Potential For Nutrition Problems,” and “Malnourished as evidenced by Nutritional Screening Tool Score of 02,” dated 6/30/2025  4. COC dated, 9/2/2025  5. RD’s progress note, dated 9/3/2025  6. Nursing Progress notes for the months of 7/2025-9/2025  7. All active and discontinued diet orders for the months of 7/2025-9/2025  8. All IDT meetings for the months of 7/2025-11/2025 The DON stated Resident 1’s meals were not consistently recorded (for every meal). There was no supporting documentation to indicate that the RD’s recommendation to provide large portion meals were endorsed to the physician and provided to Resident 1. The DON stated not following Resident 1’s care plans to monitor, record the resident’s intake and provide supplements could have caused Resident 1 to lose weight. There was no documentation to show Resident 1 was offered supplements when Resident’s intakes were below 50% on 8/20/2025, 9/11/2025, 9/15/2025- 9/16/2025, 9/18/2025- 9/19/2025, 9/22/2025- 9/23/2025 for breakfast, 9/15/2025, 9/18/2025, 9/22/2025- 9/23/2025 for lunch, and 9/5/2025, 9/13/2025-9/14/2025 for dinner. The DON stated she could not recall conducting IDT meetings after Resident 1’s identified weight loss on 9/1/2025 and did not see documentation to indicate an IDT was conducted to address the Resident’s actual weight loss. An IDT should have been conducted to address Resident 1’s weight loss and update the plan of care to ensure Resident 1 did not further decline. The DON stated staff did not follow the facility’s Policy and Procedure (P&P) titled, “Assessment and Management of Resident Weights.” A review of facility’s P&P titled, “Assessment and Management of Resident Weights” dated 5/1/2018, indicated significant weight changes were weight changes of 5% in one (1) month. The DNS (Director of Nursing Services) will notify the physician and dietician of significant weight changes, and document notification in the nurses’ notes. The P&P also indicated the licensed nurse will notify the physician of the dietician’s recommendations. If the physician does not implement the dietitian’s recommendations, the facility will document the rational for non-implementation in the medical record. The P&P indicated the IDT care plan will be updated to reflect individualized goals and approaches for managing the weight change.    The facility failed to prevent Resident 1 from having unplanned severe weight loss. The facility failed to: 1. Implement Resident 1’s Care Plan titled, “Has Potential for Nutrition Problems” which indicated to monitor and document Resident 1’s meal percentage consumed for each meal. 2. Implement Resident 1’s Care Plan titled, “Malnourished as evidenced by Nutritional Screening Tool Score of 02” which indicated to offer supplement to Resident 1 if his intake was below 50 percent. 3. Follow the RD’s recommendations on 7/14/2025 and 9/3/2025 to provide large-portion meals to Resident 1. 4. Conduct an IDT meeting to address Resident 1’s unplanned severe weight loss on 9/1/2025, make recommendations and Care Plan to prevent further weight loss. These failures resulted in Resident 1 having severe weight loss of 12.6 lbs. from 8/4/2025 to 9/1/2025 (within 28 days) and 15 lbs. from 9/15/2025 to 9/23/2025 (within 8 days). Resident 1 was transferred to the GACH and underwent a PEG tube placement. These violations, jointly, 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 for Resident 1.