Failure to Implement and Monitor Ordered Fluid Restrictions
Summary
The facility failed to ensure staff followed ordered fluid restrictions for three residents with significant cardiac and renal conditions. One resident with pulmonary hypertension, bradycardia, and heart failure had an RD-ordered 1500 ml/day fluid restriction, with 840 ml to be provided by dietary and 660 ml by nursing. The MAR showed this resident received 1680 ml of fluid in a 24-hour period, exceeding the ordered restriction. The resident’s care plan was not updated to include the fluid restriction until several days later, and the CNA care plan did not include monitoring of the restriction as a task. During a lunch observation, the resident received no fluids, and the meal ticket did not contain any information about the fluid restriction. The CNA caring for the resident stated she did not know the resident was on a fluid restriction, and the DM confirmed there was no fluid restriction noted on the meal ticket, despite facility fluid restriction instructions specifying a set amount of fluid to be provided at lunch. A second resident with congestive heart disease, chronic kidney disease, and diabetes had a physician’s order for a renal diet and a 2000 ml/day fluid restriction, with 740 ml assigned to nursing and 1260 ml to dietary. There was no care plan addressing fluid restriction for this resident, and the CNA care plan did not include monitoring of the restriction. Meal tickets for breakfast, lunch, and supper contained no documentation of a fluid restriction. During observation, the resident had a full facility-provided water pitcher of approximately 960 ml on the overbed table and 480 ml of fluid on the meal tray. The resident reported that dietary and nursing did not follow the fluid restriction and routinely provided two to three cups of fluid at each meal and a full water pitcher daily. The DM verified there was no fluid restriction noted on the meal ticket, although the facility’s fluid restriction instruction sheet specified a lower fluid amount to be provided at lunch for this level of restriction. A third resident with end stage renal disease and dependence on dialysis had physician’s orders for a renal diet and a 1500 ml/day fluid restriction, with 840 ml assigned to nursing and 660 ml to dietary. There was no care plan for fluid restriction, and the CNA care plan did not include monitoring of the restriction. Meal tickets for all meals lacked any documentation of a fluid restriction. Dialysis records showed the resident was over dry weight with 1500 ml of fluid removed on one date and 3000 ml removed on another. During observation, the resident had a facility-provided water container of approximately 720 ml on the overbed table and 240 ml of fluid on the meal tray. The resident stated that dietary and nursing did not follow the fluid restriction and that CNAs filled a 20-ounce personal water cup one to two times per day, and also reported being verbally counseled by the dialysis nurse for being over dry weight due to excessive fluid intake. The UM and Administrator confirmed that residents on fluid restrictions should have water pitchers removed, and that fluid restrictions should be documented on CNA care plans and meal tickets and followed by both nursing and dietary, as required by the facility’s “Encouraging and Restricting Fluids” policy.
Penalty
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Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
A resident with dementia, malnutrition, anemia, CKD3, and other comorbidities was care planned as at risk for nutritional decline and dehydration, with weekly weights and RD review ordered. An RD later documented poor PO intake averaging about 31%, fluid intake around 612 ml with meals, and no routine supplements in place, and recommended starting 2 oz Med Pass BID between meals with nursing to document consumption. No Med Pass order was entered into the EMR, and the resident did not receive the supplement, while experiencing a 10‑lb (6.8%) weight loss over several months. Interviews showed the RD typically communicated recommendations via email and NAR meetings, but NAR meetings had not been held consistently and no email or other system ensured the recommendation was received or implemented; requested policies on RD recommendations/supplement orders and weight loss were not provided.
Failure to monitor weights and provide ordered nutritional supplements. A resident who appeared thin and reported poor appetite after a hospital stay had a 15.8% weight loss over 6 months, yet no weekly weights were documented despite an RD order. The Dietary Manager stated the resident had orders for supplements TID and liquid protein, but none were present on the meal tray, and the resident did not recall receiving supplements with meals.
A resident with severe cognitive impairment, dysphagia, and total dependence for eating experienced a marked decline in PO intake and an 8.1% weight loss in one month. The RD documented poor meal intake (0–25% for most meals), reduced fluid intake, identified the resident as at risk for malnutrition, and recommended a reweigh and weekly weights. Despite facility policy requiring reweigh and physician notification for significant weight variance, staff did not perform a reweigh, did not obtain a November weight, and did not document provider notification. The resident was later hospitalized with poor PO intake noted and subsequently required PEG placement.
Failure to Verify Significant Weight Changes: A resident had multiple significant weight changes recorded without the required reweights for confirmation. The chart showed a large loss, then a gain, then another loss, but staff did not verify the accuracy of the weights as required by facility policy. An E4 confirmed the weights were not being checked for accuracy.
Licensed nurses completed dehydration risk assessments for a resident with severe cognitive impairment and multiple diagnoses, including dehydration, stroke, CKD, DM, and dementia, using unverified and incomplete information. On admission, an RN scored the resident’s oral intake as 75–50% and moderate risk based only on one observed meal, without reviewing hospital records or obtaining history from the resident or family. On readmission, another RN documented oral intake as 100–75% and low risk without confirming actual intake, without hospital record review, and with no reliable input from family or the resident, despite an active dehydration diagnosis, resulting in inaccurate hydration risk assessments contrary to facility policies.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Failure to Implement RD Supplement Recommendation for Resident With Weight Loss
Penalty
Summary
The facility failed to implement a registered dietician’s (RD) recommendation to address gradual weight loss for one resident. The resident was admitted with dementia with behavioral disturbance, malnutrition, anemia, osteoporosis, B vitamin deficiency, history of alcohol abuse, peripheral vascular disease, hypertension, and stage 3 chronic kidney disease. Her care plan identified her as at risk for nutritional decline and dehydration or potential fluid deficit, with approaches including weekly weights, completion of a Mini Nutritional Assessment, provision of meals per physician diet order with intake documentation, and RD review as indicated. A quarterly MDS showed severely impaired cognition, risk for pressure ulcers, receipt of a therapeutic diet, and a need for set-up or clean-up assistance with eating. On a nutritional review, the RD documented that the resident’s average intake was about 31%, average fluid intake with meals was about 612 ml, and that there were no routine supplements in place, although the RD felt she would benefit from additional support. The RD recommended initiating 2 oz Med Pass BID between meals and directed nursing to document the amount consumed. However, there was no corresponding Med Pass order in the EMR, and the resident did not receive the supplement. The resident experienced a 10‑lb (6.8%) weight loss over four months, with a low of 128.4 lbs. Interviews revealed that the RD expected recommendations to be implemented within 48 hours and typically communicated them via email to nursing and through Nutrition At Risk (NAR) meetings, but there had been no consistent NAR meetings and no email or other system in place to ensure the RD’s recommendation for Med Pass was communicated and implemented. Requested policies on RD recommendations/supplement orders and weight loss were not provided before survey exit.
Failure to Monitor Weights and Nutritional Supplements
Penalty
Summary
The facility failed to monitor weights for a resident who had significant weight loss and orders for nutritional support. The resident was observed eating breakfast and appeared thin, and she stated that since returning from the hospital she had not had much of an appetite but was trying to eat. No supplements were present on her meal tray at the time of the observation, even though the Dietary Manager later stated the resident had orders for nutritional supplements three times per day and liquid protein supplements for nutritional needs. Record review showed the resident weighed 172.2 pounds and later weighed 145 pounds, reflecting a 15.8% weight loss over 6 months. The resident was also supposed to receive weekly weights per the Registered Dietitian’s order, but no weekly weights were documented in the medical record. The Dietary Manager acknowledged the resident had been hospitalized and had lost a lot of weight, and an LPN confirmed that the ordered weekly weights were not done, stating that a restorative CNA was responsible for taking and documenting resident weights.
Failure to Reweigh and Notify Provider After Significant Weight Loss and Poor Intake
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and respond to a resident’s declining nutritional intake and significant weight loss, and to report these changes to the physician. The resident was an elderly female long‑term resident with a history of stroke with right‑sided paralysis, aphasia, oropharyngeal dysphagia, behavioral disturbance, seizures, constipation, and dementia, with severe cognitive impairment (BIMS 99) and total dependence on staff for eating. A nutrition evaluation dated 12/03/25 documented that she was on a modified texture diet with small portions, consuming approximately 75% of meals, receiving 2 Cal HN 237 ml TID, and taking 120–480 ml fluids per meal, with a weight of 171.6 lbs on 10/15/25 and an assessment that oral intake was adequate. However, a subsequent Resident at Risk Review dated 01/17/26 showed a weight of 160.4 lbs on 01/07/26 (mechanical lift), with prior weights of 175.6 lbs on 12/11/25, 171.6 lbs on 10/15/25, and 162.2 lbs on 07/06, indicating a 15.2 lb (8.1%) loss in one month and a significant change. During this period, the resident’s food intake declined to 0–25% for the majority of meals, fluid intake was 151–240 ml per meal, and she was identified as at risk for malnutrition, with oral nutritional supplements noted as her primary source of intake. The registered dietitian documented the significant weight loss, identified the resident as at risk for malnutrition, and recommended a reweigh to confirm the loss and initiation of weekly weights, noting that the weight loss had not been confirmed by reweigh. The RD also confirmed during interview that there was a documented trend of decreased intake and that she had made recommendations for reweigh and weekly weights but was unsure how these recommendations would be communicated to staff for implementation. The unit manager stated that residents are weighed monthly, that policy requires a reweigh when there is significant weight loss, and that the CNAs should perform the reweigh and the dietician and provider should be notified. He confirmed that no reweigh was done and there was no documentation of provider notification. Review of the Weights and Vitals Summary showed no November 2025 weight and no reweigh to verify the January 2026 weight, despite facility policy requiring reweigh and physician notification when there is a 5‑lb or more variance and confirmed significant variance. The hospital discharge summary later documented poor oral intake and inconsistent desire to feed prior to hospitalization, and the resident was ultimately diagnosed with severe hypernatremia and had a PEG tube placed.
Failure to Verify Significant Weight Changes
Penalty
Summary
The facility failed to obtain accurate weights and verify weights to maintain acceptable nutritional status for one resident. Facility policy required any weight change of 5% or more since the last weight assessment to be retaken the next day for confirmation. Resident 31 had a weight of 131.0 pounds on December 2, 2025, and then 111.0 pounds on January 8, 2026, a loss of 20 pounds or 15.3%, but no reweight was obtained. The resident was later recorded at 113.0 pounds on January 15, 2026, and 125.0 pounds on January 20, 2026, a gain of 14 pounds or 12.6%, again with no reweight obtained. The next recorded weight was 116.0 pounds on February 3, 2026, a loss of 9 pounds or 7.2%, and no reweight was obtained. An interview with Employee E4 on April 23, 2026, confirmed that the resident's weights were not being verified for accuracy.
Inaccurate Dehydration Risk Assessments for High-Risk Resident
Penalty
Summary
Licensed nurses failed to accurately assess and complete dehydration risk assessments for a resident with multiple complex medical conditions. The resident had diagnoses including metabolic encephalopathy, dehydration, DM, anemia, dementia, hemiplegia/hemiparesis following stroke, chronic kidney disease, and repeated falls, and was documented on the MDS as having severely impaired cognition and requiring extensive to total assistance with ADLs, including eating. On an admission dehydration risk assessment, the nurse marked the oral intake section as 75% to 50% and recorded a total score of 6, indicating moderate dehydration risk. During interview, the RN who completed this assessment stated that the intake percentage was based solely on observation of one meal on the day of admission, without obtaining additional information from hospital records, the resident, or family, and acknowledged that this did not represent the resident’s usual intake and was therefore not accurate. On a subsequent dehydration risk assessment completed at readmission, the oral intake section was marked as 100% to 75%, with a total score of 2, indicating low dehydration risk, despite the resident carrying a diagnosis of dehydration at that time. The RN who completed this assessment stated that the intake range was documented without verification of the resident’s actual intake, that hospital records were not reviewed, family could not provide intake details, and the resident was unable to report intake amounts, so the accuracy of the documented oral intake could not be confirmed. Facility policies on Dehydration Risk Assessment and Hydration Management required that residents be assessed on admission, within the assessment period, and at least quarterly, and that residents identified with potential or actual dehydration be assessed for risk factors with appropriate recommendations documented on the care plan, but the assessments for this resident were not based on accurate or complete information.
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