Failure to Complete Timely Nutritional Assessments for Two Residents
Penalty
Summary
The facility failed to complete timely nutritional assessments for two residents, resulting in incomplete medical records that did not meet accepted professional standards. Resident B, who had diabetes mellitus, was admitted on 1/28/26 and discharged on 2/13/26; a care plan dated 2/10/26 documented poor appetite and frequent refusals of meals, yet there was no documentation in the record that a nutritional assessment had been completed to evaluate this resident’s nutritional needs. Resident C, who had dementia, was admitted on 1/19/26 and discharged on 2/5/26; an admission MDS dated 1/26/26 indicated a deep tissue injury pressure ulcer was present on admission, and a care plan dated 2/2/26 documented difficulty chewing and swallowing some foods with a moderate appetite, but there was likewise no documentation of a nutritional assessment to evaluate this resident’s nutritional needs. During an interview, the RD stated she was behind and did not have enough hours at the facility to ensure nutritional assessments were completed in a timely manner.
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