Health inspection·December 5, 2025

§483.25(g) Assisted nutrition and hydration. (Include 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. 42 CFR §483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) 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: (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 of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (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. 22 CCR § 72339. Dietetic Service - Therapeutic Diets. Therapeutic diets shall be provided for each patient as prescribed and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary. 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 10/24/2025, the California Department of Public Health (CDPH) conducted an annual standard recertification survey at the facility. The facility failed to: 1. Ensure Resident 8 did not sustain severe unplanned weight loss (a weight loss greater than 5 % in one month, greater than 7.5% in three months and greater than 10 % in 6 months) of 36 pounds ([lbs. unit of measurement] 24 percent [%] in five months. 2. Ensure Resident 8's weight was taken from 5/2025 through 8/2025 as ordered by the physician. 3. Follow the facility's enumerated policies and procedures by failing to monitor, identify, and report the resident's significant weight loss in accordance with the facility's policy and procedure (P&P) titled, "Notification of Physician/Prescriber," dated 10/20/2025. 4. Monitor and report Resident 8's repeated meal refusals to the physician and Registered Dietitian (RD). 5. Notify the physician of Resident 8's refusal to eat 50 times from 6/23/2025 through 8/31/2025 and 29 times from 9/1/2025 through 9/11/2025 in accordance with the facility's P&P titled, "Notification of Physician/Prescriber," dated 7/16/2025." 6. Ensure licensed nurses informed the RD of Resident 8's poor meal intake to ensure monthly monitoring and timely nutritional recommendations. As a result, Resident 8 sustained a 36-pound weight loss over a five-month period (5/2025 through 9/2025) contributing to Resident 8's transfer to a General Acute Care Hospital (GACH) on 9/11/2025, and placing Resident 8 at risk for malnutrition, dehydration, and skin break down. These conditions, if left unaddressed, can lead to multi organ failure, severe electrolyte imbalances, muscle weakness, and death. A review of Resident 8's Admission Record, indicated Resident 8, a 62-year-old female, was admitted to the facility on 3/7/2014 with diagnoses including schizoaffective disorder, major depressive disorder, constipation and gastro-esophageal reflux disease (GERD). A review of Resident 8's Physician's Order Summary, dated 10/15/2024, indicated to weigh resident monthly. A review of Resident 8's Weights and Vitals Summary dated 4/26/2025, indicated on 4/26/2025 Resident 8 weighed 154.6 lbs. The Weights and Vitals Summary indicated there was no resident's weight recorded from 5/2025 through 8/2025, a total of four months. A review of Resident 8's RD's Nutrition Screening form, dated 6/27/2025, indicated Resident 8 mostly ate snacks throughout the day as well as consumed Ensure twice a day. The RD's Nutrition Screening form indicated the RD documented "Unclear if weight has been stable as Resident 8 has continually refused to get weighed." The RD's Nutritional Screening form indicated the goal for Resident 8 was to maintain stable weight of 155 lbs. with no significant changes through next assessment on 9/2025. The RD's Nutrition Screening form indicated the nutrition interventions included to "Monitor/evaluate oral intake, monitor/evaluate monthly weight trends, and continue to provide Ensure twice a day to supplement food intake." The RD's Nutrition Screening form indicated Resident 8's daily caloric needs were 1620 calories per day. Resident 8's usual body weight range was 147 to 157 lbs. A review of Resident 8's Meal Intake record from 6/23/2025 through 8/31/2025, indicated Resident 8 refused meals including breakfast, lunch and dinner approximately 50 times. A review of Resident 8's Minimum Data Set (MDS- a resident assessment tool) dated 7/1/2025, indicated Resident 8's height was 64 inches and weight 155 lbs. The MDS indicated that Resident 8 did not experience a weight loss of 5% or more in the past month, nor a weight loss of 10% or more in the past six months. A review of Resident 8's Documentation Survey Report (Meal Intake) from 9/1/2025 to 9/11/2025, indicated Resident 8 refused all daily meals except on 9/2/2025. On September 2, 2025, Resident 8 consumed 100% of the dinner meal only. A review of Resident 8's Meal Intake record for the period of 9/4/2025 through 9/11/2025, indicated Resident 8 refused all meals each day. A review of Resident 8's Progress Notes, dated 9/7/2025, indicated Resident 8 refused to go to the dining room for dinner, and did not eat when tray was brought to Resident 8's room on 9/7/2025. A review of Resident 8's Progress Notes, dated 9/10/2025, indicated Resident 8 was refusing breakfast, lunch, and dinner. A review of Resident 8's Progress Notes, dated 9/11/2025, and timed at 10:00 a.m., indicated Resident 8 refused his meals for five days from 9/5/2025 to 9/10/2025. Resident 8 was noted to be disorganized, disheveled, isolated, argumentative and combative. The Progress Notes indicated Resident 8 was sent to GACH on 9/11/2025 for further evaluation due to change in condition. Resident 8 returned to the facility on 9/17/2025. A review of Resident 8's MDS dated 9/26/2025, indicated Resident 8 needed partial to moderate assistance from nursing staff with showering and dressing. Resident 8 needed supervision or touching assistance from nursing staff with eating, oral hygiene, toileting and walking. Resident 8 height was 64 inches and weighed 117 lbs. Resident 8 loss 5% or more in the last month or loss 10% or more in last 6 months. A review of Resident 8's Care Plan titled "Risk for imbalanced nutrition less than body requirements related to diagnoses depression, decreased appetite, skipping breakfast most of the time as evidenced by poor intake and weight loss" dated 5/6/2025, the Care Plan goal indicated Resident 8 will be able to consume at least 75% of meal intake and will have no significant weight loss. The Care Plan interventions included encouraging and assisting Resident 8 in going to the dining room during mealtimes, providing food substitutes when refusing to eat a full meal, weighing Resident 8 as ordered and notifying Resident 8's medical doctor (MD) for any significant weight loss of 5% in a month and 10% in the last six months. A review of Resident 8's Care Plan titled "Decreased oral intake as evidenced by refusal of meals" initiated on 9/10/2025, the Care Plan goals indicated Resident 8 will maintain stable weight and will consume at least 75% of meals within one week. The Care Plan interventions included monitoring weight weekly, consulting a dietician for high calories food, high protein diet or supplements, notifying MD if poor intake persists for 72 hours or significant weight loss was noted. A review of Resident 8's Weights and Vitals Summary, dated 9/19/2025 indicated on 9/19/2025 Resident 8 weighed 117 pounds. During an interview on 10/21/2025 at 12:15 p.m., the RD stated Resident 8's scheduled lunch time was 12:30 p.m. in the dining area and that Resident 8 required encouragement to attend meals in the dining room. During an observation on 10/21/2025 at 12:43 p.m., in Resident 8's room, Resident 8 was observed seated at the edge of her bed with her head down. No meal tray was present at the bedside. During an interview on 10/21/2025 at 12:49 p.m., Certified Nursing Assistant (CNA) 1 stated she was assigned to Resident 8's room and that all of Resident 8's roommates had already received and finished their lunch in the dining room. During a concurrent interview and observation on 10/21/2025 at 12:54 p.m., in the dining room, Resident 8 was not present at in the dining room. Registered Nurse Supervisor (RNS) 2 stated that Resident 8 had not yet eaten. During an interview on 10/21/2025 at 1:01 p.m., CNA 3 stated that around 12:00 p.m., while covering CNA 1, CNA 3 encouraged Resident 8 to eat in the dining room. CNA 3 stated Resident 8 refused to go to the dining room or to eat. CNA 3 stated she did not report the refusal to a charge nurse or Registered Nurse Supervisor [RNS) in general]. CNA 3 stated that refusals should be reported shortly after meal rounds and that Resident 8 could experience weight loss if meals were not provided in a timely manner. During an interview on 10/21/2025 at 1:24 p.m., RNS 2 stated she delivered a meal tray to Resident 8 at 1:15 p.m. RNS 2 stated that if a resident refuses to eat in the dining room, a meal tray should be brought to the resident room, and the resident should be supervised during the meal. RNS 2 stated that delayed meals could lead to hunger, refusal to eat, and weight loss. During an interview on 10/23/2025 at 9:20 a.m., Licensed Vocational Nurse (LVN) 5, stated Resident 8 required encouragement to attend meals in the dining room, had poor intake, and a history of weight loss. LVN 5 stated that Resident 8's weight decreased from 154 lbs. on 4/26/2025 to 117 lbs. on 9/19/2025, a loss of 36 lbs. in five months. LVN 5 stated Resident 8 was sent to GACH on 9/11/2025 after refusing meals for six days from 9/5/2025 through 9/11/2025. LVN 5 stated Resident 8's weight loss was first identified when Resident 8 agreed to be weighed on 9/19/2025 after her return to the facility from the GACH on 9/17/2025. LVN 5 stated that Resident 8 weight was not monitored prior to 9/11/2025. During a concurrent interview and record review on 10/23/2025 at 10:29 a.m., with RNS 1, Resident 8's Point of Care (POC) Response History Meal Intake Percentage dated 9/2025 was reviewed, , the POC Response History Meal Intake Percentage indicated Resident 8 refused breakfast, lunch and dinner from 9/4/2025 to 9/11/ 2025. RNS 1 confirmed that Resident 8's weight loss was not identified until 9/19/2025, the day the resident's weight was taken. RNS 1 stated Resident 8 was hospitalized from 9/11/2025 to 9/17/2025 for not eating for six days. RNS 1 stated the RD assessed Resident 8 on 9/26/2025 upon Resident 8's return from the GACH. It was unclear whether Resident 8 was refusing food or just refusing to go to the dining room prior to hospitalization on 9/11/2025. Resident 8 had refused 29 meals from 9/1/2025 through 9/11/2025 prior to hospitalization on 9/11/2025. RNS 1 stated it was the facility's policy to notify Resident 8's MD or RD after two to three days of meal refusal. Resident 8's MD and RD were not notified of Resident 8's meals refusal because Resident 8 was consuming snacks consisting of half cheese sandwich and sherbet per physician order dated 3/13/2025. RNS 1 indicated that insufficient caloric intake may result in the resident's malnutrition. During an interview on 10/23/2025 at 11:24 a.m., the RD stated she was responsible for monitoring weights and provide recommendations for interventions to prevent weight loss, and to conduct quarterly and annual residents' nutritional assessments. She (RD) does not know when Resident 8 started to lose weight and was not aware of Resident 8's weight loss until 9/22/2025. RD stated she was not aware Resident 8 refused meals 29 times from 9/1/2025 to 9/11/2025 before being hospitalized on 9/11/2025. Resident 8's weight loss could have been prevented with prompt nutritional interventions to prevent a decline in condition and nutrition. Resident 8 would have benefited from being monitored monthly and stated that the facility has no system to monitor weight loss. RD stated she should have monitored Resident 8's meal intake. During an interview on 10/24/2025 at 4:04 p.m., the Director of Nursing (DON) stated CNAs should report residents who refuse two meals to the charge nurse and offer alternatives. It was important to identify weight loss early. Snacks alone were insufficient to meet Resident 8 daily caloric needs of 1620 calories per day per RD's assessment on 6/26/2025. Resident 8 was not meeting nutritional requirements and was at risk for complications such as skin breakdown, weakness, dehydration and malnutrition. A review of Resident 8's Physician's Orders Summary, dated 9/11/2025, indicated Resident 8 was transferred to the GACH for an evaluation of altered mental status. A review of Resident 8's GACH records, dated 9/16/2025, indicated Resident 8 was assessed with failure to thrive, altered mental status, hypernatremia, hypokalemia and elevated creatinine kinase level (CK- an enzyme found in the muscles elevated levels indicate muscle damage). The GACH records indicated Resident 8 received potassium chloride (KCI) 20 milliequivalents (mEq) one time plus a normal saline (NS) 0.9% bolus one liter one time. A review of the facility's policy and procedures (P&P) titled, "Resident Food Services,", revised on 1/2025, indicated "The [facility] will provide three meals daily at regular times comparable to standard mealtimes in the community or in accordance with resident needs, preferences, requests, and individualized plan of care. Meals are available so that no more than 14 hours elapses between the dinner/evening meal and the start time of the breakfast meal the following day except when a