GLENDORA, CA - Federal inspectors documented multiple care failures at Gladstone Sub-acute and Rehab Center, including a facility's failure to address a resident's dramatic 19-pound weight loss over eight months and inability to follow basic dietary preferences.
Significant Weight Loss Goes Unaddressed
During a June 2024 inspection, investigators found that one resident experienced progressive weight loss from 142.6 pounds in November 2023 to 123.8 pounds by June 2024. Despite this concerning 19-pound decline over eight months, facility staff failed to develop a care plan to address the weight loss or implement interventions to prevent further deterioration.
The resident, who has type 2 diabetes with diabetic neuropathy, heart failure, and gastro-esophageal reflux disease, was documented as having intact cognitive abilities and decision-making capacity. Medical records showed the resident required supervision or assistance with eating and was prescribed a controlled carbohydrate diet with no added salt, regular texture, low fat and cholesterol, and double protein with meals.
Weight loss of this magnitude in elderly nursing home residents can signal serious underlying health issues and significantly impact recovery and quality of life. Progressive weight loss can lead to muscle wasting, weakened immune function, slower wound healing, and increased susceptibility to infections.
Dietary Preferences Ignored Despite Health Consequences
Inspection records revealed that staff consistently failed to accommodate the resident's documented dietary restrictions and preferences. The resident reported that consuming foods with fat, butter, or grease caused diarrhea, yet these foods continued to appear on meal trays.
"I could have a hamburger but only a bite," the resident told inspectors. "I could eat anything but no fat, butter, or grease. I got diarrhea if I ate grease."
During one observation, inspectors found the resident with a lunch tray containing a hamburger with only two bites taken from the patty. The resident explained, "I ate as much as I can. The hamburger meat was oily."
The resident expressed frustration with the ongoing food issues, stating they were "tired of arguing regarding food preferences" and felt "like no staff were listening."
Care Planning Failures Acknowledged by Staff
When questioned about the weight loss, the facility's Assistant Director of Nursing acknowledged that no comprehensive care plan had been developed to address the resident's declining condition. The administrator stated that a weight loss care plan should have been created so "staff would know what interventions that were realistic for the resident could be done."
Facility policy required comprehensive person-centered care plans to be developed for each resident based on their individual assessed needs. These plans are designed to serve as a course of action where residents, families, attending physicians, and the interdisciplinary team work together to help residents achieve specific health goals.
Additional Care Deficiencies Found
Inspectors identified a separate violation involving improper treatment of edema in another resident. Despite a care plan specifically directing staff to elevate a resident's arms and legs to reduce swelling, facility staff consistently failed to follow these basic interventions.
During observations, inspectors found the resident lying in bed with swollen fingers and forearms, but with arms flat on the mattress rather than elevated on pillows as required. Nursing staff confirmed that elevation was necessary to prevent blood clots and skin breakdown, yet the intervention was not being implemented.
"If facility staff did not elevate the resident's arms then there was an increased risk for the resident to develop blood clots and there was increased risk of skin breakdown," one treatment nurse explained to inspectors.
Medical Significance of Weight Loss in Nursing Homes
Unintentional weight loss among nursing home residents is considered a serious quality indicator and potential marker of inadequate care. The Centers for Medicare & Medicaid Services tracks weight loss as a key measure of nursing home quality, recognizing its connection to resident health outcomes.
For residents with multiple chronic conditions like diabetes and heart failure, maintaining adequate nutrition becomes even more critical. Proper nutrition supports blood sugar management, heart function, and overall recovery from illness or injury. When dietary preferences and restrictions are not followed, residents may avoid eating, leading to malnutrition and accelerated health decline.
Gastro-esophageal reflux disease, one of the resident's documented conditions, can be significantly worsened by fatty foods. Consuming foods that trigger symptoms can lead to reduced appetite, poor nutrient absorption, and the exact type of progressive weight loss documented in this case.
Regulatory Requirements and Standards
Federal nursing home regulations require facilities to ensure that residents receive adequate nutrition and that meal planning takes into account individual dietary needs, preferences, and restrictions. Care plans must be comprehensive and address all aspects of a resident's health status, including nutritional needs and weight maintenance.
When residents experience significant weight loss, facilities are required to investigate causes, develop interventions, and monitor progress. This includes working with registered dietitians, adjusting meal plans, providing supplements if necessary, and addressing any barriers to adequate nutrition.
The facility's own policies emphasized providing "necessary care and services to assist residents in attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care."
Industry Context and Best Practices
Standard practice in long-term care requires ongoing monitoring of resident weights, with significant changes triggering immediate assessment and intervention. Weight loss of more than 5% in one month or 10% in six months is considered clinically significant and requires investigation.
Best practices include regular nutrition assessments, individualized meal planning, accommodation of food preferences and cultural needs, and close monitoring of residents with swallowing difficulties or chronic conditions affecting nutrition. Facilities typically employ registered dietitians to oversee nutrition programs and ensure residents receive appropriate care.
Implications for Resident Care
The documented failures at Gladstone Sub-acute and Rehab Center highlight critical gaps in basic nursing home care. When facilities fail to address progressive weight loss or implement basic interventions like elevation for edema, residents face increased risks of complications, longer recovery times, and potential health deterioration.
These violations were classified as having "minimal harm or potential for actual harm," but the cumulative effect of inadequate nutrition monitoring and care plan failures can have serious consequences for vulnerable residents who depend on nursing home staff for all aspects of their daily care and medical management.
The inspection findings underscore the importance of comprehensive care planning, attention to individual resident needs, and consistent implementation of prescribed interventions in nursing home settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gladstone Sub-acute and Rehab Center from 2024-06-13 including all violations, facility responses, and corrective action plans.
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