Health inspection·June 14, 2024

§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; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet. 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. 22 CCR § 72315(h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. On 4/30/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to evaluate and modify the diet texture to meet the nutritional needs for Resident 103. As a result, there was a 26.35 percent ([%] a part of every 100) or 39 pounds ([lbs.] unit of measurement) unplanned weight loss, within a six-month period for Resident 103. A review of Resident 1's Admission Record, indicated the 62-year-old male resident was admitted to the facility on 11/1/2023, with diagnoses including diabetes mellitus type 2 ([DM] abnormal blood sugar), essential hypertension ([HTN] high blood pressure), anemia (a condition in which the body does not have enough healthy red blood cells), and hemiplegia (weakness of one side of the body that could affect the arms, legs and facial muscles). A review of Resident 103's Minimum Data Set ([MDS] a standard assessment and care screening tool), dated 2/9/2024, indicated Resident 103 was cognitively intact (able to understand and make decisions). The MDS indicated Resident 103 was able to eat with supervision or touching assistance (where the helper provided verbal cues) and or touching or contact guard assistance (a caregiver places one or two hands on the resident's body to help with balance) as the resident completed the activity. A review of Resident 103's Physician's orders indicated the following: a. 11/2/2023- Regular standard portion diet (diet with no restriction), regular texture thin consistency b. 11/19/2023- DM (sugar free oral supplement) 8 oz, high protein nourishment three times a day. c. 1/3/2024-Regular- standard portion diet, mechanical soft chopped texture (a diet consisting of food that are soft and chopped), regular/thin consistency. d. 1/6/2024-Fortified (a process of adding extra nutrients to food by adding margarine, butter, and cream), mechanical soft chopped texture, regular/Thin consistency. Snacks at bedtime for nourishment. e. 3/11/2024- snacks three times a day with meals with soup and vegetables for lunch and dinner. f. 4/15/2024-Fortified puree diet (a type of diet consisting of foods with pudding like consistency) with thin liquids with meals. A review of Resident 103's weight record dated from 11/2/2023 to 4/30/2024 titled "Weights and Vitals summary," indicated the following weight trends: 11/02/2023:148 pounds- admission weight 11/23/2023:146 lbs. 1.35% (2 lbs.) weight loss since 11/02/2023 (3 weeks) 11/26/2023: 148 lbs. 1.37% (2 lbs.) weight gain in 3 days 12/6/2023: 145 lbs. sitting: 2.03% (3 lbs.) weight loss since 11/26/2023 (10 days) 2.03% (3 lbs.) weight loss since 11/2/2024 (1 month) 1/5/2024: 142 lbs., 2.7% (3 lbs.) weight loss since 12/7/2023 (1 month) 4.05% (6 lbs.) weight loss since 11/2/2023 (2 months) 1/21/2024:142 lbs. mechanical lift (a device used to move person who is unable to stand on their own): no weight loss since 1/5/2024 (1 month) 2/6/2024:140 lbs. sitting: 1.41% (2 lbs.) weight loss since 1/5/2024 (1 month) 1.41% (2 lbs.) weight loss since 1/21/2024 (2 weeks) 3/5/2024: 136.7 lbs. sitting: 2.36 % (3.3 lbs.) weight loss since 2/6/2024 (1 month) 3.73 % (5.3 lbs.) since 1/5/2024 (2 months) 5.72% (8.3 lbs.) since 12/6/2023 (3 months) 7.64% (11.3 lbs.) since 11/2/2023 (4 months) 3/11/2024: 133.6 lbs. sitting: 2.27% (3.1 lbs.) weight loss since 3/5/2024 (1 week) 4.57% (6.4 lbs.) weight loss since 2/6/2024 (1 month) 5.92% (8.4 lbs.) weight loss since 1/5/2024 (2 months) 7.86% (11.4 lbs.) weight loss since 12/6/2023 (3 months); severe 9.73% (14.4 lbs.) weight loss since 11/2/2023 (4 months); severe 3/19/2024: 132.4 lbs. sitting: 0.9% (1.2 lbs.) weight loss since 3/11/2024 (1 week) 5.43% (7.6 lbs.) weight loss since 2/6/2024 (approximately [~ ]1 month); severe weight loss (a weight loss of more than five (5) lbs. in 1 month, more than 7.5 lbs. in three (3) months and more than ten (10) lbs. in six (6) months.) 6.76% (9.6 lbs.) weight loss since 1/5/2024 (~2 months) 8.69% (12.6 lbs.) weight loss since 12/7/2023 (~3 months); severe 10.54% (15.6 lbs.) weight loss since 11/2/2023 (~4 months); severe 3/26/2024:130.1 lbs. sitting: 1.74% (2.3 lbs.) weight loss since 3/19/2024 (1 week) 2.62% (3.5 lbs.) weight loss since 3/11/2024 (~2 weeks) 4.83% (6.6 lbs.) weight loss since 3/5/2024 (~3 weeks) 7.07% (10 lbs.) weight loss since 2/6/2024 (~2 months) 8.38% (11.9 lbs.) weight loss since 1/5/2024 (~3 months); severe 8.69% (12.6 lbs.) weight loss since 12/6/2023 (~4 months); severe 10.54% (15.6 lbs.) weight loss since 1/2/2024 (~5 months); severe 4/2/2024: 120.8 lbs. mechanical lift: 7.15% (9.3 lbs.) weight loss since 3/26/2024 (1 week) 8.76% (11.6 lbs.) weight loss since 3/19/2024 (~2 weeks) 9.58% (12.8 lbs.) weight loss since 3/11/2024 (~3 weeks) 11.63% (15.9 lbs.) weight loss since 3/5/2024 (~ 1 month); severe 13.71% (19.2 lbs.) weight loss since 2/6/2024 (~2 months); severe 14.93% (21.2 lbs.) weight loss since 1/5/2024 (~3 months); severe 16.69% (24.2 lbs.) weight loss since 12/6/2023 (~4 months); severe 18.38% (27.2 lbs.) weight loss since 11/2/2023 (~5 months); severe 4/9/2024: 114.8 lbs. mechanical lift: 4.97% (6 lbs.) weight loss since 4/2/2024 (1 week) 11.76% (15.3 lbs.) weight loss since 3/26/2024 (~2 weeks) 13.29% (17.6 lbs.) weight loss since 3/19/2024 (~3 weeks) 14.07% (18.8 lbs.) weight loss since 3/11/2024 (~ 1 month); severe 16.02% (21.9 lbs.) weight loss since 3/5/2024 (~1 month); severe 18% (25.2 lbs.) weight loss since 2/6/2024 (~2 months); severe 19.15% (27.2 lbs.) weight loss since 1/5/2024 (~3 months); severe 20.83% (30.2 lbs.) weight loss since 12/6/2023 (~4 months); severe 22.43% (33.2 lbs.) weight loss since 11/2/2023 (~5 months); severe 4/15/2024: 114.8 lbs. mechanical lift: no weight change since 4/9/2024 4/23/2024: 114.8 lbs. mechanical lift: no weight change since 4/9/2024 11.8% (15.3 lbs.) weight loss since 3/26/2024 (~1 month); severe 19.2 % (27.2 lbs.) weight loss since 2/4/2024 (~2 months); severe 22.4% (33.2 lbs.) weight loss since 11/2/2023 (~5 months); severe 4/30/2024:109 lbs. mechanical lift: 5.05% (5.8 lbs.) weight loss since 4/23/2024 (1 week) 9.77% (11.8 lbs.) weight loss since 4/2/2024 (~4 weeks); severe 20.26% (27.7 lbs.) weight loss since 3/5/2024 (~2 months); severe 22.14% (31 lbs.) weight loss since 2/6/2024 (~3 months); severe 23.24% (33 lbs.) weight loss since 1/5/2024 (~4 months); severe 24.83% (36 lbs.) weight loss since 12/6/2023 (~5 months); severe 26.35% (39 lbs.) weight loss since 11/2/2023 (~6 months); severe During a concurrent observation and interview with Resident 103, on 4/30/2024, at 11:58 a.m., Resident 103 was lying in bed and unable to use his left hand. Resident 103 stated he had a toothache and was unable to chew hard vegetables served in the facility and he lost weight. Resident 103 stated he preferred a puree diet (smooth foods with pudding-like consistency) because it was easier for him to eat. Resident 103 stated the staff started offering him a puree diet only three days ago. During a concurrent interview and record review with Registered Dietitian 1 (RD 1) on 5/1/2024, at 10:35 a.m., Resident 103's medical records and nutritional assessment were reviewed. RD 1 stated on 11/17/2023, she completed Resident 103's initial nutritional assessment and Resident 103 reported he had difficulty chewing, and digestion problems after he had a stroke and he preferred liquid- based foods. RD 1 stated Resident 103 wanted a high protein nutrition (HPN, shakes high in protein and calorie) at that time and she recommended HPN sugar free assorted flavor with meals. RD 1 stated the dietary supervisor saw the resident and wrote food preferences after 11/17/2023. RD 1 stated Resident 103 was on a regular diet upon admission and on 3/6/2024, his diet was changed to a mechanical soft diet (soft and chopped foods) with snacks, once a day. RD 1 stated on 3/11/2024, she met with Resident 103 because he was flagged for significant weight loss from 148 lbs., on 1/2/2024, to 136.7 lbs. on 3/5/2024 (a total weight loss of 11.3lbs in two months). RD 1 stated Resident 103 had 5.3 lbs. weight loss in 1 month. RD 1 stated Resident 103's weight loss was due to variable food intake of 50 to 100% as indicated on his chart. RD 1 stated Resident 103's food intake was not meeting his nutritional needs. RD 1 stated on 3/11/2024, Resident 103's diet was fortified (process of adding extra nutrients to food like margarine, butter, and cream) mechanical soft diet, with snacks once a day and HPN. RD 1 stated Resident 103 requested to update his food preferences so he could get yogurts for all snacks, soups, soft vegetables, and oatmeal with all meals. RD 1 stated she assessed Resident 103 again on 4/3/2024, and his diet was still mechanical soft, fortified diet with three snacks per day plus HPN. RD 1 stated she recommended megace (a medication to improve appetite) to stimulate Resident 103's appetite but did not change the diet's texture. RD 1 stated Resident 103's weight on 3/5/2024, was 136.7 lbs. and dropped to 130.1 lbs. on 3/26/2024 (6.6 lbs. weight loss in 21 days). RD 1 stated her next assessment for Resident 103 was on 4/10/2024, and Resident 103 had lost 15.9 lbs., in one month from 136.7 lbs. on 3/5/2024, to 120.8 lbs. on 4/2/2024. RD 1 stated Resident 103's diet was a fortified mechanical soft diet. RD 1 stated Resident 103's weight loss was due to his poor food intake of 26 - 76% which was not meeting his nutritional needs. RD 1 stated Resident 103 requested puree foods and ensure (a type of high protein, high calorie shake) with all meals. RD 1 stated she assessed Resident 103 again on 4/30/2024 because Resident 103 was not eating at all. RD 1 stated she could have visited Resident 103 more often and switched the diet to puree diet sooner for a better food intake as Resident 103's main concern was his food intake. RD 1 stated she did not usually attend weight variance meetings, but she met with the Director of Nursing (DON) because the meetings were scheduled on the days she was not in the facility. During a concurrent interview and record review with the Dietary Supervisor (DS 1) on 5/1/2024, at 2:35 p.m., of Resident 103's medical records and nutrition notes were reviewed. DS 1 stated Resident 103 had poor food intake and progressive weight loss. DS 1 stated Resident 103 was a picky eater and liked soups and vegetables. DS 1 stated on 2/6/2024 Resident 103 was on a mechanical soft diet with no chewing or swallowing problems. DS 1 stated she assessed Resident 103 on 4/3/2024, and Resident 103 was on a mechanical soft fortified diet with HPN for 3 days. DS 1 stated Resident 103 had a 10 lbs. weight loss in one month due to varied food intake of 26 to 100%. DS 1 stated she updated Resident 103's food preferences and added fortified soups, oatmeal, soft vegetables, and yogurts, but did not change the consistency. DS 1 stated her next visit with Resident 103 was on 4/9/2024, and his diet was mechanical soft chopped fortified. DS 1 stated fortification of food varied from every meal like adding margarine, cheese to soup or toppings on the dessert to add extra calories for residents with weight loss. DS 1 stated Resident 103 was eating hot cereals, soups, HPN three times a day, snacks three times a day. DS 1 stated Resident 103 liked soft vegetables, beans, ice cream and disliked meats, chicken, pork, beef, bread and would not even eat fish. DS 1 stated Resident 103 wanted oatmeal so he could pour his health shakes in it. DS 1 stated the facility changed Resident 103's diet to puree on 4/15/2024, because Resident 103 stated it was easy for him to eat pureed foods. During a concurrent record review of weight variance meeting for Resident 103 and interview with DS 1 on 5/1/2024, at 3:00 p.m., DS 1 stated weight variance meetings were conducted every Thursdays and the DON, DS 1, Activities Director (AD), and social services were in attendance. DS 1 stated the first interdisciplinary ([IDT]a group of professionals with a common goal to meet a resident's needs) meeting for weight variance for Resident 103 was on 4/5/2024. DS 1 stated Resident 103 had 9.3 lbs. weight loss in one month due to variable food intake. DS 1 stated IDT met for weight variance meeting on 4/11/2024 due to six lbs. weight loss in one week because of poor food intake. DS 1 stated Resident 103 was hospitalized on 5/1/2024 due to further weight loss. During an interview with Certified Nursing Assistant (CNA) 9 on 5/2/2024, at 10:54 a.m., CNA 9 stated Resident 103 was a picky eater, would complain about his food being hard and difficult to chew. CNA 9 stated Resident 103 only ate soups and oatmeal when he was on soft mechanical diet. CNA 9 stated about four to six months ago, Resident 103 stated that the meals served him were too hard and he preferred soft to chew foods. During an interview with CNA 10 on 5/2/2024, at 11:09 a.m., CNA 10 stated Resident 103 meal intake was 60%, because Resident 103 did not eat the vegetables and complained the vegetables were hard to chew. CNA 10 stated she always notified the charge nurse about the resident's complaints of his food texture, but nothing was done. CNA 10 stated Resident 103 ate better (80%) when he was on puree diet. During a concurrent interview and record review with Utility Manager (UM, a Licensed Vocational Nurse [LVN]), on 5/2/2024, at 5:47 p.m., Resident 103's medical record was reviewed. The UM stated Resident 103 had weight loss concerns from 3/6/2024 and lost 5.3 lbs. in a month. The UM stated the facility had a weight variance meeting on 3/7/2024 and discussed Resident 103's diet as fortified mechanical soft, with bedtime snacks. The UM stated Resident 103 complained he had a hard time chewing meat because he had partial dentures, and he did not like wearing them. The UM stated the resident was not educated on a mechanical soft diet during the meeting and his diet was not changed to a puree diet. During a concurrent interview and record review with the UM on 5/2/2024, at 6 p.m., Resident 103's diet order dated 11/2/202,3 and 3/6/2024, were reviewed. The UM stated the diet order dated 11/2/2023, indicated Resident 103 was to be served a regular diet. The UM stated the diet order dated 3/6/2024, indicated mechanical soft diet. The UM stated that Resident 103's diet was changed to fortified soft mechanical diet but there was no modification or downgrade in consistency. The UM stated that on 3/21/2024 the IDT met again to discuss Resident 103's weight variance but did not talk about changing Resident 103's diet. The UM stated the staff was to continue serving soups and vegetables to Resident 103. The UM stated on 3/29/2024, the IDT met because Resident 103 had continued to lose weight. The UM stated Resident 103 would get oatmeal for breakfast and monitored for weekly weights. The UM stated there was no discussion on changing Resident 103's diet. The UM stated on 4/5/2024, the IDT met, and the plan was to serve Resident 103 ice cream with lunch and dinne