Failure to Address Significant Weight Loss
Summary
The facility failed to ensure adequate dietary services were provided to prevent significant weight loss for one resident who had diagnoses including pneumonia, cerebral infarction, diabetes mellitus, severe morbid obesity, dementia, chronic pain syndrome, dysphagia, psychosis, and adjustment disorder with anxiety. The resident’s care plan identified her as at risk for altered nutritional status related to diabetes mellitus and a mechanically altered/therapeutic diet. Her weight declined from 323.6 pounds to 271.5 pounds in about one month, and the record documented a 13.15% weight loss. The registered dietitian noted the significant weight loss and attributed it to fluid shifts, with no further nutritional interventions documented at that time. Speech therapy later evaluated the resident because of difficulty taking medications and decreased oral intake and recommended a puree diet, which was then ordered by the physician. After the diet change, nursing notes documented that the resident’s meal intake decreased because she did not like the puree diet and that she refused to eat pureed food. The resident’s husband stated she had not been eating since the diet was changed. The resident continued to lose weight, with documented weights showing further decline to 258 pounds and then 246.8 pounds, totaling 21.05% weight loss from the earlier baseline and 23.73% over six months. The record showed delayed and limited dietary intervention after the significant weight loss was identified. The dietitian did not document ongoing monitoring or recommendations to prevent further weight loss until later, when Boost glucose control twice daily was ordered and the diet was eventually upgraded to mechanical soft with chopped meats after the resident and her husband agreed. The medical record also showed no laboratory tests were performed to evaluate nutritional status during the period of continued weight loss. Interviews with the RD, DON, NP, and Medical Director confirmed the resident’s weight loss was significant and unplanned, that the Boost twice daily was not enough to sustain her weight, and that the resident’s weight loss had not been adequately addressed when first identified.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Lack of Certified Dietary Manager: The facility failed to employ a full-time CDM for the 32 residents receiving meals from the kitchen. Dietary CC was observed overseeing meal prep, but he stated he was not CDM certified and had not been enrolled in any certification classes. An admin nurse verified he was not certified, while the facility policy required the Food Services manager to be CDM certified or enrolled in an accredited CDM program.
RD oversight of dietary services was not provided as expected under the contract. The CDM completed the monthly kitchen sanitation and food storage audits, while the RD came to the facility about once per week for meetings, did not review or sign the audits, did not provide kitchen staff in-service training, and did not observe tray line or dining operations. The RD stated her 24 hours per week were not enough to complete all required tasks, and the DON and Administrator both acknowledged gaps in the RD’s direct oversight and resident observation.
Insufficient food service and nutrition staffing was identified when the facility lacked an on-site FSD to manage kitchen operations, and the person serving as a dietary technician did not have the credentials for that role. Interviews showed the per diem FSD only came in weekly to order food and supplies, the RD worked remotely, and staff described the kitchen as having no management. A resident also reported that dietary staff had not checked preferences or updated the meal plan.
Failure to Maintain a Qualified Full-Time Dietary Manager: The facility did not have a full-time qualified DM when the RD was not employed full-time. The CDM worked only part time or as needed, the DM was still in training and not qualified, and the RD was present only about eight hours a week. This was associated with puree foods not being in the proper form, puree foods not being prepared to conserve nutritive value and flavor, menus not being followed, and food storage cool-down procedures not being monitored for 31 residents.
Unqualified dietary leadership and missing Food Protection Manager certification. The Dietary Manager was supervising kitchen operations and reported serving as the full-time PIC, but denied having the qualifications of a clinically qualified CDM or equivalent training and denied holding Food Protection Manager certification. The Dietary Manager also stated no other dietary staff had that certification, and the facility dietician did not work full-time in the building. The Facility Assessment listed a Certified Dietary Manager in the staffing plan, and surveyors also observed nonfunctional sink basins plus an unsanitary can opener and ice scoop.
Lack of Full-Time Dietary Leadership: The facility did not have a full-time CDM or qualified dietician/clinically qualified nutrition professional on site to oversee kitchen staff and residents’ dietary needs. Dietary Staff BB was serving as CDM for two kitchens while also working at another facility, and Consultant GG stated she oversaw seven facility kitchens and only visited this facility on Fridays; neither she nor the CDM worked over 35 hours per week at the facility.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for the 32 residents who received meals from the facility kitchen. During observation of the noon meal on 06/02/2026, Dietary CC was seen in the kitchen overseeing preparation of pork loin, oven-roasted potatoes, carrots, and a Jello parfait. On 06/01/2026 at 08:00 AM, Dietary CC stated that he was not a Certified Dietary Manager (CDM) and had not been enrolled in any dietary certification classes. On 06/03/2026 at 09:00 AM, Administrative Nurse D verified that he was not certified and planned to enroll him in classes at the end of June. The facility’s Food and Nutrition Services policy dated 10/2021 stated that the Food Services manager would be CDM certified or enrolled in an accredited CDM program and on pace for completion.
RD Did Not Provide Required Kitchen Oversight or Dietary In-Service
Penalty
Summary
The facility failed to ensure a Registered Dietitian (RD) was on site enough time to carry out kitchen and dietary oversight for a census of 94 residents who ate from the kitchen. The RD was contracted through Nutrition That Works, LLC, and the agreement stated the service provider would assess nutritional needs, provide guidance and training to dietary staff, plan and conduct in-service education, inspect all areas of the dietary department including sanitation and food service operations, and be available at various mealtimes to observe dining operations. During interviews and record review, the Certified Dietary Manager (CDM) confirmed he completed the monthly kitchen sanitation and food storage audits and that the RD did not review or sign them. The CDM stated the RD came to the facility about once per week for a meeting, did not provide kitchen staff education or in-service training, and did not observe tray line. The RD confirmed she was only contracted for 24 hours per week and did not go into the kitchen, provide oversight of dining operations, complete in-service training, or perform kitchen sanitation audits and reports. The DON stated she expected the RD to physically observe each new resident, and the Administrator stated he was unaware the RD did not have kitchen oversight as required by the contract.
Insufficient Food Service and Nutrition Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietitian. The facility assessment documented that the former Food Service Director was on medical leave and that a per diem Food Service Director was being used. The current staff list identified the Nutrition Assistant as a dietetic technician, and the job descriptions showed that the Food Service Director role required leadership and direct supervision of dietary staff, while the dietetic technician role involved nutritional care planning, resident interviews, meal intake monitoring, and verification of diet orders. During interviews, multiple staff and residents described the absence of on-site management in the kitchen. The Ombudsman Coordinator stated food was the biggest issue at the facility and that the kitchen staff had no management. A resident stated no one from dietary had come to check preferences or update the meal plan. A staff member stated there had been no kitchen manager for at least two weeks, and that the per diem Food Service Director only came in to train new kitchen managers and order food and supplies. Another dietary staff member stated the night shift usually had only two or three staff total. Additional interviews showed that the per diem Food Service Director was only in the building once a week to review inventory and order supplies and food, and did not oversee the kitchen or handle meal preparation, cleaning, or meal accuracy. The former Food Service Director stated they had not worked in the facility since December 2025 and that the per diem director was only responsible for ordering food. The Registered Dietitian stated they provided remote support, while the Administrator stated they were managing day-to-day kitchen operations and that the Nutrition Assistant was acting as the dietary technician despite not having certifications or credentials in nutrition. The report also states the facility had a registered dietitian on record who worked remotely and was never seen in the facility.
Failure to Maintain a Qualified Full-Time Dietary Manager
Penalty
Summary
The facility failed to ensure there was a full-time qualified Dietary Manager who met California Health and Safety Code requirements when the Registered Dietitian was not employed full-time. The report states that the facility did not have a full-time dietetic services supervisor meeting state requirements, and that the DM was still enrolled in a program, about halfway complete, and under the supervision of the RD. The RD stated she was usually at the facility once a week, and later said the plan was for her to be at the facility at least eight hours a week, depending on need. During interviews and record review, the Certified Dietary Manager stated she worked at the facility only part time or as needed and helped with clinical duties only. The Administrator stated the RD worked about eight hours a week, the CDM had another job and only worked as needed, and the DM was in school and not qualified at that time. The deficiency was associated with puree food not being in the proper form, puree foods not being prepared by methods that conserve nutritive value and flavor, menus not being followed, and food storage not being monitored for cool down procedures for the 31 residents admitted to the facility.
Unqualified dietary leadership and missing Food Protection Manager certification
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. On 5/20/2026 at 12:05 PM, V4, identified as the Dietary Manager, was actively supervising dietary operations in the facility kitchen and reported being the full-time manager of the food service and PIC. V4 stated they were not a clinically qualified Certified Dietary Manager and did not have equivalent training, and also denied being a certified Food Protection Manager. V4 further denied that any other dietary staff were certified Food Protection Managers. V4 also reported that the facility dietician does not work in the facility full-time. V4 denied having any of the qualifications listed for the Director of Food and Nutrition Services, including being a dietician, a Certified Dietary Manager, having an associate's or higher degree in food service management or hospitality, having 2 or more years of experience as a director of food and nutrition services in a nursing facility, graduating from an approved dietetic and nutrition program, graduating from an approved pre-7/1/1990 course with required experience, or completing an approved Certified Dietary Manager or Certified Food Protection Professional course. The Facility Assessment (2025) documented that the staffing plan includes a Certified Dietary Manager. On 5/20/2026 at 12:30-12:45 PM, the facility also failed to maintain functional sink basins and failed to maintain a sanitary can opener and ice scoop. The Room Directory dated 5/20/2026 documented that 61 residents reside in the facility.
Lack of Full-Time Dietary Leadership
Penalty
Summary
The facility failed to provide the services of a full-time Certified Dietary Manager (CDM) for residents who received meals from the kitchen. On 05/20/26 at 11:00 AM, Dietary Staff BB verified that she was the CDM for the two facility kitchens but also continued to work at another facility. During an interview on 05/21/26 at 09:35 AM, Administrative Staff A stated there should be a full-time CDM on site and that this was the expected transition for Dietary Staff BB. Administrative Staff A also verified there should be a qualified dietician or other clinically qualified nutrition professional working full-time in the facility to oversee the kitchen staff and residents’ dietary needs. During an interview on 05/21/26 at 11:05 AM, Consultant GG verified she was overseeing seven facility kitchens and currently visited this facility on Fridays, and then verified that neither she nor the CDM were working over 35 hours a week at the current facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.