A resident admitted with muscle wasting and atrophy had documented weight changes from 164 lbs to 178.6 lbs, then dropped to 156.6 lbs, triggering a Dietitian note for significant weight loss and a reweight request. The reweight was delayed, the resident was later documented at 153 lbs, and no further Dietitian follow-up or additional nutritional interventions were put in place after the weight loss was identified; staff also did not follow the facility’s weekly weight monitoring schedule for newly admitted residents.
Failure to timely assess and monitor residents’ nutrition needs. A resident with dysphagia and weight loss did not receive a timely RD assessment or documented nutrition follow-up after an NP ordered a consult, and later continued to lose weight before being seen again. Another resident admitted with dysphagia had a delayed admission nutrition assessment and missed weight monitoring. A third resident with brittle DM, variable BGs, and DKA had no recent comprehensive nutrition assessment or dietary notes for months, despite the MD stating close follow-up was expected.
Failure to Monitor Weight Loss and Nutritional Status: A resident with multiple hospital transfers and readmissions had inconsistent weight monitoring, including a delayed post-readmission weight record and a documented 8.6-lb loss in 10 days. The Dietitian confirmed the lack of required weight documentation after the most recent readmission and that no interventions or follow-up care were provided for the significant weight loss; the DON validated the findings.
Failure to provide ordered nutritional supplements: A resident with a physician order for Magic Cup and Health shakes TID for risk of malnutrition reported not receiving them as expected. Survey observations found the supplements missing from breakfast and lunch trays and meal tickets, while the MAR documented them as administered. An LPN stated the items were obtained from the kitchen at breakfast and acknowledged they were documented as given before the resident actually received them.
Failure to provide a replacement meal after breakfast was not consumed. A resident with cognitive impairment and recent weight loss was observed away from the room while the breakfast tray remained untouched and the plate was found on the floor with oatmeal and eggs spilled. The DON was notified and housekeeping cleaned the spill, but there was no evidence the resident was assessed for intake or offered a replacement tray, substitute meal, or nutritional supplement. The CDM said no extra breakfast tray was requested, and an RN stated she was unaware the resident needed a replacement meal.
A resident with Parkinson’s disease and tremors was observed having difficulty feeding him/herself at breakfast, with food placement problems due to hand tremors and lethargy noted during the observation. The resident had been assessed as malnourished and was receiving nutritional supplements, but intake was partial or refused, and the care plan lacked interventions for reduced intake. The GNA believed the resident could feed independently, while the MD, dietitian, and DON were unaware of the feeding difficulty.
Failure to address and communicate significant weight changes for two residents. One resident had large, fluctuating weight changes with no documentation that the early drops and gains were investigated, re-weighed for accuracy, or addressed with interventions. Another resident had a 14.6 lb weight loss after hospitalization, but there was no evidence the provider was notified. The DON validated the lack of documented communication, and the Dietitian stated significant weight changes should be addressed and that nursing is responsible for reporting them.
Failure to timely address and communicate significant weight loss. A resident had repeated hospital transfers/readmissions and showed major weight loss on facility weights, including a 12.7% loss followed later by another 6.7% loss. The RD documented weight loss and added nutrition interventions, but there was no evidence the changes were reported to the family or attending MD. Interviews showed conflicting staff understanding of who was responsible for notifying family/providers, and the DON, ADON, and Regional DON validated the concern.
Facility staff failed to follow dietitian recommendations and physician follow-up for two residents with weight loss and malnutrition. For one resident with dementia, FTT, and mild protein-calorie malnutrition, staff did not obtain or file results of an ordered GI telehealth consult and missed one of the weekly weights ordered by the dietitian. For another resident with malnutrition, staff obtained only two of four recommended weekly weights, and the dietitian did not reassess the resident after the initial evaluation. These inactions resulted in incomplete monitoring and follow-up for residents identified as experiencing weight loss.
Failure to provide ordered double portions: An underweight resident with declining wt was supposed to receive a regular diet with double portions of entree and vegetables, but surveyors found the lunch tray missing the protein and the 2 chicken salad sandwiches listed on the meal ticket. The resident confirmed the sandwiches were not received, and the dietary mgr later confirmed the resident should have gotten them.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.