Health inspection·July 8, 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. 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 5/20/25, the California Department of Public Health (CDPH) conducted an annual standard recertification survey at the facility. The facility failed to prevent Resident 116 unplanned weight loss (a weight loss greater than 5 % in one month) of 29 pounds ([lbs.] 18.59 % percent [%] in 6 months) from 1/2025 to 5/2025. The facility failed to: 1. Ensure Registered Dietician's recommendations for Resident 116's weekly weights, protein supplement, double portions for breakfast, appetite stimulant (medication that stimulates appetite) and to have a blood test done for a complete metabolic panel (CMP- blood test) and a prealbumin (blood test used to indicate nutritional deficiencies) were carried out. 2. Ensure a Change of Condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) for severe weight loss was completed on 1/2025 when Resident 116 had a weight loss of 10 lbs. (6.4 % loss), on 2/2025 when Resident 116 had a weight loss of 8 lbs. (11.5% loss), 4/2025 when Resident 116 had a weight loss of 9 lbs. (17.3% loss) and on 5/2025 when Resident 116 had a weight loss of 2 lbs. (18.59% loss), total of 29 lbs. in 6 months. 3. Ensure facility's staff followed Resident 116's care plan titled, "Altered in Nutrition" dated 3/14/2025 to monitor and report Resident 116's weight loss and poor oral intake to the physician. 4. Ensure there were weekly interdisciplinary team (IDT- a group of professionals from different disciplines who work together to achieve a common goal) weight variance meetings from 1/2025 through 5/2025 to address Resident 116 weight loss. 5. Develop a comprehensive care plan with interventions to prevent Resident 116 weight loss. As a result of these failures Resident 116's had severe weight loss of 29 lbs. (18.59 % of body weight) in 6 months. A review of Resident 116's Admission Record, indicated Resident 116 was admitted to the facility on 12/4/2024 and readmitted on 2/10/2025 with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), kidney transplant (replaces a failing kidney with a healthy one from a living or deceased [dead] donor) legally blind (vision loss), gastro-esophageal reflux (GERD- burning sensation in chest). Resident 116 was discharge from the facility on 2/5/2025 to the general acute care hospital (GACH) due to altered mental status (a change in a person's mental function or level of consciousness, encompassing a range of symptoms from mild confusion to coma [a deep state of unconsciousness, where a person is alive but unable to respond to their environment ]) and readmitted back on 2/10/2025. A review of Resident 116's Registered Dietician (RD) Food and Nutrition Assessment initiated on 12/10/2024 and completed on 12/30/2024, indicated Resident 116's weight was 156 lbs. on 12/7/2024 and the resident was consuming 76% to 100% of her breakfast, lunch and dinner. Resident 116's re-admission weight on 2/10/2025 was 140 lbs. The RD's Food and Nutrition assessment also indicated Resident 116 should have been consuming 1775 to 2125 calories (a unit of energy used to measure the energy content of food) per day to maintain her admission weight. The RD's Food and Nutrition assessment also indicated that Resident 116 had a low pre albumin level and RD's recommendation was to start 30 milligrams (mg - unit of measurement) of sugar free protein supplement two times a day (BID). A review of Resident 116's Physician's Order Summary Report dated 2/10/2025, indicated an order for Fortified (a diet in which certain essential nutrients have been added to foods to improve their nutritional value) Consistent Carbohydrate Diet (CCHO- diet f or resident with diabetes). A review of Resident 116's History and Physical (H&P) dated 2/11/2025, indicated Resident 116 had the capacity to understand and make decisions. A review of Resident 116's Minimum Data Set (MDS - a resident assessment tool) dated 4/13/2025, indicated Resident 116 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 116 needed partial to moderate assistance (helper does half the work) with activities of daily living (ADLs- activities such as bathing, and dressing a person performs). The MDS indicated Resident 116 height was 62 inches (unit of measurement) and weighed 138 lbs. The MDS indicated Resident 116 was on a therapeutic diet (specialized meal plans designed to treat or manage specific medical conditions by controlling nutrient intake) and the resident had no weight loss of 5% in the last month or loss of 10 % or more in the last six months. A review of Resident 116's Weights and Vitals Summary from 12/2024 through 5/2025, indicated Resident 116's weight was as follows: 1.On 12/7/2024 Resident 116 weight was 156 lbs. 2.On 12/16/24 Resident 116 weight was 150 lbs. (3.85 % weight loss). 3.On 1/1/2025 Resident 116 weight was 146 lbs. (6 .4 % weight loss). 4.On 2/4/2025 Resident 116 weight was 138 lbs. (11.5 % weight loss). 5. On 2/10/2025 (readmission weight) Resident 116 weight was 140 lbs. (9.7 % weight loss). 6. On 4/3/2025 Resident 116 weight was 129 lbs. (17.31 % weight loss). 7. On 5/22/2025 Resident 116 weight was 127 lbs. (18.59 % weight loss). A review of Resident 116's RD's recommendations dated 3/6/2025, indicated the resident's weekly weights for two weeks. A review of Resident 116's RD's recommendations dated 3/10/2025, the RD recommended was to discontinue Health Shakes (beverage, intended to be a healthy addition to a diet) and, provide snack three times a-day (TID) and to give 30 milliliters (ml-unit of measurement) of liquid protein (essential nutrient for the structure, function, and regulation of the body's tissues and organs) daily. A review of Resident 116's RD's Weight Change Note dated 3/10/2025 indicated Resident 116 weight was stable at 138 lbs. and it was discussed in IDT meeting. RD's recommendation indicated to have the resident's weekly weights for two weeks. A review of Resident 116's RD's recommendations dated 3/11/2025, indicated to check CMP and prealbumin, weekly weights for two weeks and double portions at breakfast. A review of Resident 116's Multidisciplinary Quarterly Care Conference dated 3/12/2025, indicated Resident 116 was consuming between 26% to 50% of her breakfast, lunch and dinner. Resident 116's weight goal was 150 lbs., and she weighed 138 lbs., and that the family had requested for the resident to have a snack three times a day. A review of Resident 116's care plan titled "Alteration in Nutrition" dated 3/14/2025 and revised on 5/22/2025 the care plan focus indicated that Resident 116 had lost 9.0 lbs. between 3/2025 through 4/2025. The care plan goal indicated for Resident 116 to consume 75% of her meals. The care plan interventions indicated to notify Resident 116's doctor and family of weight gain or loss of 5% or 5 lbs. in one month. On 5/19/2025 Resident 116 started on Glucerna (nutritional shake) one time a day, ordered on 5/18/2025. A review of Resident 116's Situation, Background, Assessment, and Recommendations ([SBAR] a technique which is used to facilitate prompt and appropriate communication within the care team) communication form dated 3/31/25, indicated Resident 116 had no appetite and had lost nine lbs. in two months (2/4/2025- 4/3/2025). The SBAR indicated to have recommendation from Resident 116's primary doctor and RD consult. A review of Resident 116's RD's recommendations dated 4/7/2025, the RD's recommendation was to do weekly weights for four weeks, check CMP, prealbumin and to call the medical doctor (MD) for an appetite stimulant. A review of Resident 116's RD's Weight Change Note dated 4/07/2025 indicated Resident 116's weight was 129 lbs. and that she was refusing meals and had a significant weight loss for in one month and three months. The RD's Weight Change Note indicated Resident 116 was at risk for further weight loss due to her refusal of meals and poor food intake. The RD's Weight Change Note indicated the RD attempted to discuss appetite and meal refusal and weight loss with Resident 116 on 4/7/2025, but she was asleep, and Resident 116's response was "I know speak English". The RD informed Resident 116 she would have a Spanish speaking staff follow up with her. The RD's Weight Change Note also indicated that further weight loss would be undesirable. The RD's recommendations were to do weekly weights for four weeks, check CMP, prealbumin and call the medical doctor (MD) to request an appetite stimulant. A review of Resident 116's Order Summary Report (summary of active, completed, discontinued, on hold or struck out physician orders) from 12/01/2024 through 5/31/2025, indicated Resident 116 was started on a protein supplement on 1/30/2025 which was discontinued on 2/10/2025. The Order Summary Report indicated Resident 116 was started on Glucerna on 5/19/2025. A review of Resident 116's Medication Administration Record (MAR) dated 2/31/2025, indicated that Resident 116 had an order for a protein supplement 30 ml two times a day to start on 1/30/25 and was discontinued on 2/10/2025. A review of Resident 116's, CMP results report dated 4/7/2025, the CMP results report indicated Resident 116's albumin was 3.0 grams per deciliter (g/dL-reference range is 3.5 to 5.7 g/dL). During an interview on 5/20/2025 at 11:28 a.m., Resident 116's Family Member 1 (FM1), stated Resident 116 had lost a lot of weight since her admission to the facility on 12/4/2024. FM 1 stated they had been bringing Resident 116 lunch and dinner every day because she does not like the food at the facility as it was too sweet and she has DM. FM 1 stated the facility has not told them how much weight Resident 116 had lost but FM 1 knows it was a lot because last month (April) her eyes were sunken in prior to Resident 116's doctor discontinued a medication (unknown). FM 1 stated he had informed someone in the facility (unknown) that Resident 116 wanting a protein shake in the morning because she refuses to take her medication without food. FM 1 stated they live very far from the facility and cannot bring her breakfast, that was the reason they requested a protein shake because Resident 116 will not take her medications until FM 1 bring her food. During a concurrent interview and record review on 5/22/2025 at 7:47 a.m., with the Assistant Director of Nurses (ADON) Resident 116's clinical record (Weights and Vitals Summary, COC documentation and IDT meeting notes) were reviewed, from 12/2024 through 5/2025. The ADON stated that in December Resident 116's admission weight was 156 lbs. and that in April the resident's weight was 129 lbs. The ADON stated the only documentation she could find was a COC that was done on 3/31/2025 for a 9.0 lb. weight loss. The ADON stated there should have been a COC done on 1/2025, 2/2025, and 4/2025 when Resident 116 continued to have a weight loss. The ADON stated Resident 116 should have had IDT meetings for weight loss and a comprehensive care plan should have been developed when Resident 116 started losing weight in 1/2025. The ADON stated the RD should have brought this resident's weight loss to IDT weight variance meetings in 1/2025 when Resident 116 had a10 lbs. weight to discuss interventions to prevent the resident's future weight loss and to keep better track of the resident's condition. During a concurrent interview and record review on 5/22/2025 at 9:15 am with the RD, Resident 116's weights and RD's recommendations from 12/2024 through 5/2025 were reviewed. The RD stated that Resident 116 did have a weight loss of 10 lbs. in 1/2025 and had lost 6.4% of her body weight with no RD recommendations. The RD stated that in 2/2025, Resident 116 had lost another 9.0 lbs. and lost 11.5% of her body weight with no RD recommendations. The RD stated she did not know about the resident's weight loss until 3/2025 when Resident 116 weighed 138 lbs. and that was the reason why nothing was done for Resident 116's weight loss in 1/2025 and 2/2025. On 3/6/2025 RD's recommendation for weekly weights for two weeks was not done. On 3/10/2025 RD's recommendation to give 30 ml of a protein supplement TID was not done. On 3/11/2025 RD recommendation for weekly weights for two weeks, double portions for breakfast and blood work for CMP and pre albumin, were not done. RD stated that in 4/2025 Resident 116 had lost another 9.0 lbs. and had lost 17.3% of her body weight. RD stated she had recommended on 4/7/2025 to do weekly weights for four weeks, give an appetite stimulant and do a pre-albumin level and those intervention were not done. The RD stated a weight loss of 5 % in one month 7.5 % in three months and 10% in 6 months constitute a significant weight loss, and a weight loss greater than 7.5% in 3 months and greater than 10% was a severe weight loss. The RD stated Resident 116 was receiving 300 calories a day less than estimated needs in 1/2025, 160 calories a day less in 2/2025 and 70 calories a day less in 4/2025. The RD stated she did not talk to Resident 116 or FM 1 regarding her weight loss because Resident 116 could not speak English. RD stated there were no IDT meetings done for Resident 116's weight loss and that there should ha