F0656

E

Failure to Implement Care-Planned Nutritional Interventions

Altoona, Pennsylvania Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the implementation of a resident-centered care plan related to nutritional interventions for Resident 2. A comprehensive MDS assessment dated September 4, 2025 documented that the resident was cognitively impaired and dependent on staff for daily care tasks, including feeding, and had increased nutrition risk due to requiring staff assistance and having swallowing difficulties. The resident’s care plan, last updated on the same date, specified that an alternative meal was to be offered whenever the resident consumed less than fifty percent of a meal.

Review of the resident’s November 2025 meal intake records showed multiple instances where the resident ate less than fifty percent of meals across breakfasts, lunches, and dinners on numerous dates throughout the month. There was no documented evidence that an alternative meal was offered on any of these occasions, despite the care plan requirement. In an interview on February 12, 2026 at 2:14 p.m., the Director of Nursing confirmed there was no indication that the resident had been offered an alternative meal on those dates and acknowledged that the resident should have been offered one according to the care-planned intervention.