SPOKANE, WA - A January 2025 state inspection revealed serious nutritional care failures at Royal Park Health and Rehabilitation Center, where two residents experienced substantial weight loss due to delayed interventions and inadequate supervision of prescribed dietary protocols.
Major Weight Loss Goes Unaddressed for Months
The most concerning case involved a cognitively intact resident who experienced a dramatic 23-pound weight loss over eight months while facility staff failed to implement timely interventions. The resident, who entered the facility weighing 182 pounds in December 2023, saw their weight plummet to as low as 154.8 pounds by October 2024 - a decline that triggered multiple warning signs throughout 2024.
Documentation shows the resident first appeared before the facility's nutrition committee in May 2024 after losing 11 pounds in April alone. Despite this significant monthly loss, no immediate interventions were implemented at that time. The situation worsened through the summer, with the resident losing an additional 7.5% of their body weight by August 2024.
It wasn't until August 23, 2024 - after the resident had already lost over 20 pounds - that the facility finally ordered calorie-dense supplements and nutritionally enhanced meals. By September, a provider documented that the resident had developed protein-calorie malnutrition with muscle wasting in their abdomen, thighs, and face.
During the inspection, the resident expressed frustration with the delayed response, stating they had "lost 30 lbs, from 180 lbs down to 160 lbs, and it bothers me." The resident also complained about the quality of facility food, saying "the food is horrible" and attributing their weight loss to "disliking the facility food."
Critical Supervision Failures Put Resident at Risk
Inspectors documented equally serious violations in the care of a second resident with dementia and swallowing difficulties. This resident, who had physician orders for constant supervision during meals and specialized equipment due to aspiration risk, was repeatedly observed eating and drinking without any staff oversight.
The resident was prescribed mildly thickened liquids, sippy cups for all beverages, and aspiration precautions requiring upright positioning and careful monitoring. However, inspection observations on multiple days in January 2025 revealed the resident eating alone in their room without supervision. Even more concerning, staff provided regular cups instead of the prescribed sippy cups and served beverages with ice cubes, which can thin prescribed liquid consistencies and create choking hazards.
This resident had also experienced significant weight decline, dropping from 172.4 pounds in June 2024 to 157.5 pounds by December 2024 - a 9.1% weight loss over six months. Despite clear signs of nutritional decline and increased aspiration risk, interventions weren't implemented until December 2024.
Medical Consequences of Delayed Interventions
Unplanned weight loss in nursing home residents creates cascading health risks that extend far beyond nutritional concerns. When elderly residents lose significant weight, their immune systems become compromised, wound healing slows, and their bodies lose muscle mass needed for mobility and basic functions.
Protein-calorie malnutrition, as developed by the first resident, represents a serious medical condition where the body begins breaking down muscle tissue for energy. This process, known as muscle wasting, can affect the heart muscle and respiratory function, making residents more vulnerable to infections and complications.
For residents with swallowing difficulties, proper supervision and equipment aren't merely preferences - they're life-saving protocols. Aspiration pneumonia, which occurs when food or liquid enters the lungs instead of the stomach, remains one of the leading causes of death in nursing home residents. The prescribed sippy cups control liquid flow rate, while thickened liquids move more slowly through the throat, giving residents with dysphagia more time to coordinate their swallowing reflexes.
Industry Standards Require Proactive Intervention
Current healthcare standards emphasize early identification and intervention for weight loss in nursing home residents. Facilities should implement nutritional support when residents lose 5% of their body weight in one month or 10% over six months - thresholds both residents exceeded well before interventions began.
Best practices require regular monitoring of food intake, immediate notification of healthcare providers when concerning patterns emerge, and prompt implementation of dietary modifications or supplements. The standard of care also mandates strict adherence to prescribed dietary restrictions and supervision requirements, particularly for residents with documented swallowing difficulties.
Modern nutritional care plans should include multiple intervention strategies, from preferred food preferences and meal timing adjustments to medical nutrition therapy and appetite stimulants when appropriate. The goal is preventing weight loss rather than responding after significant decline has occurred.
Staff Acknowledge Systemic Problems
During interviews, facility staff members acknowledged multiple failures in the identified cases. The Resident Care Manager admitted that "if supplements were ordered sooner, it could have potentially prevented Resident 77 from losing so much weight." The Administrator stated the facility "implemented interventions when weight loss was identified, not prior to weight loss."
A nursing assistant explained they "did not have enough staff" to provide required meal supervision for residents eating in their rooms, revealing staffing challenges that directly impacted resident safety. The Director of Nursing confirmed that residents requiring sippy cups should receive them for all liquids and that thickened liquid residents should never receive ice cubes due to aspiration risks.
Additional Issues Identified
The inspection also documented problems with weight monitoring protocols, including inconsistent weighing methods that affected accuracy of loss calculations. Staff failed to follow established care plan interventions and didn't maintain proper documentation of dietary intake percentages. The facility's nutrition committee, while identifying concerning trends, failed to trigger timely medical interventions or modify care plans appropriately.
The violations represent systemic failures in the facility's nutritional care program, affecting not just individual residents but indicating broader problems with protocol implementation, staff training, and clinical oversight that could impact the entire resident population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Park Health and Rehabilitation from 2025-01-17 including all violations, facility responses, and corrective action plans.
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