PALM SPRINGS, CA - A state health inspection at California Nursing & Rehabilitation Center uncovered multiple residents experiencing severe, unaddressed weight losses over three-month periods, along with significant food safety violations including contaminated ice machines and improperly stored food. The inspection, conducted from February 24 through March 3, 2025, resulted in an immediate jeopardy declaration affecting all 72 residents at the facility.
Critical Weight Loss Cases Went Unmonitored for Months
Five residents at the Palm Springs facility experienced severe weight changes that were not properly addressed by medical staff, according to state inspection findings. The most concerning case involved a resident who lost 23 pounds in less than two months - a 12.3% decrease in body weight - without receiving reassessment from the facility's registered dietitian or having the weight loss addressed by their physician.
The inspection revealed a pattern of systematic failures in nutritional monitoring. One diabetic resident lost 16 pounds (8.04% of body weight) over three months without being placed on weekly weight monitoring, despite having uncontrolled diabetes mellitus. Another resident with hyperlipidemia and a body mass index of 16.5 - already classified as underweight - lost 14 pounds (11.67% of body weight) without receiving appropriate interventions.
A third resident experienced a 16-pound weight gain (10.26%) while diagnosed with hypothyroidism and chronic kidney failure, conditions that require careful weight monitoring. The facility failed to implement weekly weight tracking or have a physician address the significant weight fluctuation. A fifth resident with dysphagia and hemiplegia lost 8.6 pounds (5.78%) without reassessment to determine if current interventions were preventing further decline.
The facility's registered dietitian acknowledged during the inspection that she had recently transitioned to full-time dietary services manager but had previously worked part-time at the facility. She reported spending only 70-75% of her time on clinical nutrition care, with the remainder dedicated to food service tasks.
Medical Significance of Unaddressed Weight Loss
Severe weight loss in nursing home residents represents a critical health indicator that can signal underlying medical conditions, inadequate nutrition, or systemic care failures. When residents lose more than 5% of body weight in one month or 10% over six months, it constitutes a significant clinical event requiring immediate intervention.
For diabetic residents, uncontrolled weight loss can indicate poor glucose management and increases the risk of diabetic complications including neuropathy, kidney damage, and cardiovascular events. The 16-pound loss experienced by the diabetic resident without intervention violates standard medical nutrition therapy protocols, which require weekly weight monitoring until stabilization occurs.
Residents with existing malnutrition indicators, such as the individual with a BMI of 16.5, face particularly severe consequences from additional weight loss. A BMI below 18 already indicates underweight status, and further losses can compromise immune function, delay wound healing, increase infection risk, and accelerate muscle wasting. The 14-pound loss in this already undernourished resident represented a dangerous progression that required immediate nutritional intervention.
The resident with dysphagia who lost weight faced unique risks, as swallowing difficulties already compromise nutritional intake. Weight loss in dysphagic residents often indicates inadequate texture modification, insufficient caloric density in modified foods, or progression of the underlying swallowing disorder. Standard protocols require immediate reassessment of diet texture, supplementation strategies, and potential feeding assistance needs.
Contaminated Ice Machine and Temperature Violations Expose Residents to Foodborne Illness Risk
Kitchen inspections revealed multiple critical food safety violations that exposed all residents to potential foodborne illness. The facility's ice machine contained "dark brown and black debris inside the bin, on and inside the ice cubes," along with a "light brown pinkish colored slimy substance" throughout the internal components, according to inspection documentation.
The maintenance supervisor stated he cleaned the ice machine only once monthly using dish soap and an aqueous solution. Both the director of nursing and dietary services manager acknowledged the contamination was unacceptable, with the dietary manager stating that residents with weakened immune systems "could get sick, be hospitalized, and even death if they consume the ice."
Reach-in freezer temperatures repeatedly measured between 41.9 and 55 degrees Fahrenheit during multiple inspection checks, far exceeding the required temperature of 0 degrees or below for frozen food storage. Ice cream stored in the freezer was "very soft" and containers were "bendable," indicating complete thawing of frozen products. These temperature violations can allow rapid bacterial growth and compromise food safety.
Kitchen staff demonstrated inadequate knowledge of food safety protocols. One cook incorrectly tested dish machine sanitizer levels, measuring 300-400 parts per million when the maximum safe level was 100 ppm. A dietary aide could not properly calibrate food thermometers, a critical skill for ensuring safe food temperatures.
Industry Standards Require Comprehensive Nutritional Monitoring
Professional standards from The Academy of Nutrition and Dietetics explicitly require registered dietitians to monitor weekly body weights for residents experiencing unintended weight loss until stabilization occurs. California regulations mandate that dietitians reassess residents with significant weight changes, collaborate with interdisciplinary teams, and modify nutritional interventions within prescribed diet parameters.
The facility's own policies required the dietitian to assess residents quarterly for nutritional concerns including weight variance and abnormal laboratory values. The dietitian services contract specifically outlined responsibilities for addressing significant weight loss through recommendations and interventions to meet estimated nutritional needs.
Federal food safety codes establish clear requirements for equipment sanitation and temperature control that the facility repeatedly violated. Ice machines require regular cleaning and sanitization to prevent biofilm formation and bacterial growth. Freezer temperatures must maintain 0 degrees Fahrenheit or below to prevent bacterial multiplication and food spoilage.
The medical director stated during the inspection that physicians should document how they address weight loss and ensure interventions are appropriate with dietitian involvement, emphasizing that "weight is a very important component of a resident's medical and nutrition status because it helps them gain strength to fight off diseases."
Additional Issues Identified
The inspection also revealed the facility's diet manual had not been updated or signed for 2025, leaving dietary protocols potentially outdated. Kitchen staff failed to follow therapeutic diet menus, serving white rice instead of prescribed brown rice to residents on renal diets, potentially affecting their phosphorus and potassium intake management.
Multiple wet and contaminated dishes were found stored with clean dishes, including metal pans with water and food debris stacked together, strainers with dried white residue, and skillets with dried particles. Cutting boards showed multiple indented markings indicating wear that could harbor bacteria.
Staff training deficiencies extended beyond food temperature monitoring. Kitchen personnel could not properly test sanitizer concentrations in dish machines or understand appropriate chemical levels for safe dishwashing. Monthly kitchen inspection reports from August 2024 through January 2025 documented recurring issues including incomplete drying of silverware, food debris in storage bins, and inadequate freezer temperatures.
The facility failed to ensure menus met nutritional requirements for residents with specialized dietary needs. Two residents requiring renal diets received incorrect food items that could compromise kidney function management. The dietary services manager confirmed that following approved therapeutic menus was essential for providing appropriate nutrition based on medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for California Nursing & Rehabilitation Center from 2025-03-03 including all violations, facility responses, and corrective action plans.
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