Failure to Implement and Communicate Fluid Restrictions for a Resident
Summary
The facility failed to maintain acceptable parameters of nutritional status for Resident #286, who was on fluid restrictions due to End Stage Renal Disease and undergoing hemodialysis. The physician's order for fluid restrictions was not initiated or communicated to the nursing and dietary departments for eight days. The order specified a fluid restriction of 1200cc per day but did not include instructions on how to distribute this amount throughout the day. This lack of communication and clarity in the physician's order led to the resident not receiving the appropriate care to maintain his well-being. Resident #286, a male with moderately impaired cognition, was unaware of his fluid restrictions and continued to consume fluids without limitation. The facility's records, including the Medication Administration Record (MAR) and meal tickets, did not reflect the fluid restrictions, and staff members, including the Medication Aide and Charge Nurse, were not informed of the restrictions. The dietary staff also did not receive any communication regarding the fluid restrictions, resulting in the resident receiving more fluids than prescribed. Interviews with facility staff, including the Vice President of Clinical Operations (VPCO) and Director of Nursing (DON), revealed that the discrepancy between the hospital discharge order and the facility's order was not noticed, and the fluid restrictions were not implemented since the resident's admission. The facility's policy on fluid restrictions was not followed, as the physician's order was not verified, and the distribution of fluids was not communicated to the relevant departments. This oversight placed the resident at risk for fluid overload, which could lead to serious health complications.
Penalty
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The facility failed to provide ordered nutritional supplements with meals for two residents who required assistance and monitoring for nutrition and hydration. One resident with dementia, dysphagia, and severe cognitive impairment, fully dependent on staff for feeding, had orders for a health shake with meals and a magic cup to be given with meals and alternated with bites of food, but was only given the regular breakfast items without the health shake and without the magic cup being offered as ordered. Another resident with hyperkalemia, chronic fatigue, and moderate cognitive impairment, who was at risk for altered nutrition and had an order for a magic cup supplement with each meal, was observed eating breakfast without being offered the supplement. A CNA reported being unaware of some of these supplement orders despite diet cards in the kitchen, and the Administrator reported there was no policy on supplemental orders.
The facility failed to consistently document meal intake percentages for three residents who were care planned as being at risk for malnutrition, dehydration, and significant weight loss, and who required extensive assistance with eating and other ADLs. Despite care plan interventions directing staff to monitor and record meal percentages at each meal, record reviews showed numerous missing entries for breakfasts, lunches, and dinners over multiple months. A CNA reported documenting meal intakes after meals and not leaving before completing charting, while the DON stated that aides are expected to chart daily and that meal percentages are used to monitor nutritional status. Facility policy required nutrition documentation for all residents in accordance with regulatory and practice standards.
A resident with Alzheimer’s disease, CHF, metabolic encephalopathy, an unstageable sacral pressure ulcer, and essential tremor, who had impaired cognition and required staff assistance with eating, toileting hygiene, bed mobility, and transfers, did not have weights monitored according to the facility’s Weight Management policy. The policy required weights on admission, weekly for four weeks, and then monthly, but documentation showed only three weights were obtained, with no further weights recorded before the resident was transferred to the hospital. The UM confirmed both the policy requirements and the absence of additional documented weights, resulting in a cited deficiency for failure to follow the facility’s weight-monitoring protocol.
A resident with a history of UTIs, hypotension, protein-calorie malnutrition, and dysphagia had a dietary recommendation and physician order for an extra 240 ml of fluids with lunch and dinner to support hydration. Over an extended period, intake records showed low average daily fluid intake and no documentation that the ordered extra fluids were consistently provided. A supper meal ticket lacked the extra fluid order, observation showed only one standard beverage and a UTI supplement, and the DM reported being unaware of the extra fluid requirement, with no notation on the dietary reminder sheet. An LPN later confirmed the order existed, and the resident’s daughter reported ongoing concerns about inadequate hydration, dark urine, decreased urination, and recurrent UTIs.
Two residents experienced significant weight loss without appropriate individualized nutrition care planning or required weight monitoring. One resident with dementia and other psychiatric diagnoses had documented weight decline and a dietician‑ordered change in Med Pass supplements, but weekly weights were not obtained as required, the new supplement order was not entered for many days, and the care plan was not updated to reflect the weight loss. Another resident with neurologic and psychiatric conditions had multiple documented weight changes, but admission and weekly weights were not consistently taken, and no care plan was developed to address the weight loss, despite a dietician note identifying a significant one‑month weight change and ordering changes to tube feeding and continued monitoring.
A resident with CHF, muscle weakness, prior small bowel resection, and impaired cognition required assistance with ADLs and supervision with eating, and was care planned for nutrition/hydration risk and weight monitoring with supplements. The facility failed to obtain the resident’s scheduled monthly weight and did not identify that the resident, who had decreased appetite and moderate reduction in food intake, experienced a significant unplanned weight loss between one month and the next recorded weights. The diet technician later confirmed the weight was missed despite daily IDT meetings and that the resident frequently refused meals without staff notifying nursing or dietary, contrary to the facility’s weight monitoring policy requiring at least monthly weights and weekly weights for residents with weight loss.
Failure to Provide Ordered Nutritional Supplements With Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements to residents as specified in their physician orders and care plans. One resident with severe cognitive impairment, dementia, depression, dysphagia, and dependence on staff for feeding had care plan interventions for staff to feed all meals and snacks and physician orders for a regular diet with pureed texture and mildly thick liquids. The care plan and orders included a health shake with meals for weight gain and a magic cup with meals, to be offered alternating with bites of food per speech therapy. During a breakfast observation, the resident was fed oatmeal, eggs, fruit, and thickened juice by a CNA, but the magic cup was not provided in between bites of food, and the health shake was not provided at all. The CNA confirmed awareness that the resident should receive a magic cup but did not know it was to be given between bites and was unaware of the health shake order, despite diet orders being available in the kitchen. Another resident with hyperkalemia, chronic fatigue, weakness, moderate cognitive impairment, and risk for altered nutrition and hydration status had care plan interventions to offer substitutes when meal intake was less than 50%, monitor weights, and provide nutritional supplements as ordered. The resident’s diet had been changed from mechanically altered to regular with thin liquids, and there was a physician order for a magic cup supplement with meals. During a breakfast observation, the resident was seen eating eggs, bacon, and toast without being offered a magic cup. The CNA later confirmed that the diet card indicated the resident should receive a magic cup with each meal but acknowledged that the supplement was not offered and that they were unaware of the order. The Administrator stated there was no policy on supplemental orders. This deficiency was cited under a complaint investigation.
Failure to Consistently Document Meal Intake for Residents at Nutritional Risk
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure meal intakes were consistently documented for residents identified as being at nutritional risk, which was necessary to maintain residents’ health and monitor nutritional status. For one resident with Huntington’s disease, dysphagia, abnormal weight loss, bipolar disorder, and adult failure to thrive, the care plan identified risks for altered nutrition, dehydration, and significant weight loss, with interventions that included monitoring and documenting meal percentages at each meal. Record review showed multiple missing meal intake entries across January, February, and March 2026 for this resident, including undocumented breakfasts, lunches, and dinners on numerous specific dates, despite the care plan requirement to document each meal. A second resident, admitted with Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease, was care planned as being at risk for malnutrition, altered fluid maintenance/dehydration, and significant weight loss, with interventions to monitor and document meal percentages for each meal. Review of this resident’s records revealed missing documentation of meal percentages for several breakfasts, lunches, and dinners in January, February, and March 2026. These gaps occurred even though the resident required substantial/maximal assistance with eating and was dependent on staff for several ADLs, and despite the care plan directive to document each meal consumed. A third resident with non-traumatic subdural hemorrhage, visual hallucinations, Down syndrome, chronic pain syndrome, and left foot drop was also care planned as being at risk for malnutrition, altered fluid maintenance/dehydration, and significant weight loss, with interventions to monitor and document meal percentages at each meal due to consuming less than 75% of meals and needing assistance with meals. Record review showed numerous missing meal percentage entries for this resident’s breakfasts, lunches, and dinners across January, February, and March 2026. CNA #122 stated that meal intakes are recorded after meals and that she does not leave her shift until documentation is complete, while the DON stated that aides are expected to chart daily, including meal percentages, and confirmed that meal percentages are used to monitor residents’ nutritional status. Facility policy on nutrition documentation required that nutrition documentation be completed on all residents in accordance with regulations and standards of practice.
Failure to Monitor Resident Weights per Facility Policy
Penalty
Summary
The facility failed to obtain and monitor a resident’s weights in accordance with its Weight Management policy, which required all residents to be weighed on admission, weekly for four weeks, and then monthly or as indicated by the physician. One resident with diagnoses including Alzheimer’s disease, an unstageable sacral pressure ulcer, metabolic encephalopathy, congestive heart failure, and essential tremor was admitted with impaired cognition, required moderate assistance with eating, and was dependent on staff for toileting hygiene, bed mobility, and transfers. Record review showed this resident was weighed on admission at 164 lbs and then on two subsequent occasions at 165.2 lbs and 164.2 lbs, with no further weights documented before the resident was hospitalized and did not return. In an interview, the unit manager confirmed the facility’s weight-monitoring expectations and verified that no additional weights were obtained or recorded for this resident beyond the three documented weights, despite the resident remaining in the facility until hospital transfer. This deficiency was cited as non-compliance with the facility’s weight management policy under Complaint Number 2709811.
Failure to Provide Ordered Extra Fluids for Hydration
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered fluids to maintain a resident’s hydration status. The resident had diagnoses including recurrent urinary tract infections, hypotension, gastric reflux, protein-calorie malnutrition, and dysphagia, and had a dietary recommendation for 1950 ml fluid intake daily. After a hip fracture and readmission, the dietitian documented a recommendation and an order was obtained for an extra 240 ml of fluids with lunch and dinner, and this was also reflected on a diet order and communication form. Fluid intake records from 02/11/26 to 03/12/26 showed the resident’s intake per meal ranged from 60–240 ml, with an average daily intake of 760 ml, and there were days with missing meal intakes and several recorded refusals. There was no evidence in the records or care plans that the ordered extra 240 ml of fluids at lunch and dinner was being consistently provided or documented. Surveyor review of a supper meal ticket showed no indication of the extra 240 ml fluid order, and observation of the resident at supper revealed only one 240 ml cup of beverage and a 120 ml cup of UTI supplement, not the ordered additional fluids. The Dietary Manager stated she was unaware of the extra fluid order and confirmed that special dietary instructions should appear on the meal ticket and a reminder sheet in the kitchenette; the extra fluid order was not listed on that sheet. An LPN reviewed the orders with the surveyor and confirmed the resident was supposed to receive extra fluids with lunch and dinner, but this had not been communicated to dietary. The resident’s daughter reported concerns about inadequate hydration, including decreased urination, dark urine, and recurrent urinary tract infections, and stated she did not feel her concerns about her mother’s hydration needs had been addressed.
Failure to Implement Individualized Nutrition Care Plans and Required Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain individualized, comprehensive nutrition plans and appropriate weight monitoring for two residents, in accordance with its own weight assessment policy. For one resident with Alzheimer’s disease, dementia, and intermittent explosive disorder, the admission orders included a regular diet with Med Pass supplement and the care plan identified risk for malnutrition due to diagnoses, depression, and supplement use. However, the care plan was not revised or individualized to address subsequent weight loss. Weight records showed a decline from 121.2 lbs on admission to 110 lbs over several weeks, and weekly weights were not obtained as required during the first four weeks after admission. The registered dietician documented a significant 8% one‑month weight loss and ordered a change in the Med Pass supplement regimen and continued weight monitoring per physician order. Despite this, the original Med Pass order was not discontinued until 11 days later, and the new Med Pass order was not entered into the system or reflected on the MAR until that same later date. Interviews with the RD, the regional director of operations, and the DON confirmed that weights were not taken on admission and weekly for four weeks as required, that weights were not monitored weekly after the significant weight change, that the supplement order change from 01/19/26 was not entered until 01/30/26, and that the nutrition care plan was not updated to reflect the resident’s weight loss. For another resident with cerebral infarction, schizophrenia, and psychoactive substance abuse, the care plan did not include any plan for weight loss. Weight records showed an admission weight of 164 lbs, followed by weights of 166 lbs, 156 lbs, and 154 lbs, and the resident’s weight was not taken at admission or weekly for four weeks as required by policy. The RD later documented a significant 7% one‑month weight change and ordered changes to tube feeding (Jevity 1.5) and continued nutrition monitoring with weights per physician order. However, interviews confirmed that required admission and weekly weights were not obtained, that weekly weights were not taken after the significant weight loss, and that there was no care plan addressing the resident’s weight loss, contrary to the facility’s policy requiring multidisciplinary, individualized care plans for weight loss or impaired nutrition.
Failure to Obtain Monthly Weight Resulting in Unrecognized Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to obtain a required monthly weight for a cognitively impaired resident with multiple medical conditions, resulting in an unrecognized, significant unplanned weight loss. The resident had diagnoses including unspecified systolic congestive heart failure, muscle weakness, and unspecified intestinal obstruction, and required a wheelchair for mobility, supervision or touching assistance with eating, and substantial assistance with ADLs. The care plan identified self-care performance deficits related to limited mobility, anemia, cognitive communication impairment, polyneuropathy, hypotension, and congestive heart failure, and included interventions such as setting up meal trays, encouraging self-feeding, offering assistance or finger foods, opening and cutting food, and notifying the nurse if the resident was not eating. The care plan also identified risk for nutrition and hydration deficits related to a recent small bowel resection and planned significant weight gain, with interventions including weighing as ordered, providing supplements as ordered, and monitoring for signs and symptoms of malnutrition and significant weight loss. Despite these identified risks and interventions, the medical record showed that the resident’s weight was recorded as 142 lbs in early December, but no weight was obtained in January, contrary to the facility’s weight monitoring policy that required monthly weights for all residents and weekly weights for residents with weight loss. Subsequent weights in early February showed a drop to 123.6 lbs and then 121.4 lbs. A dietician progress note documented that the resident reported decreased appetite, had a moderate decrease in food intake over the prior three months, was receiving Ensure daily and was receptive to increasing it to twice a day, and had a mini nutrition score indicating malnutrition, with a notation that no January weight was recorded. In an interview, the diet technician confirmed the resident had a significant weight loss, should have been weighed weekly, and was not weighed in January, stating the missed weight must have been overlooked during daily interdisciplinary team meetings and acknowledging that the resident frequently refused to eat and that staff should have notified nursing or the diet technician if the resident was refusing meals.
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