Surveyors found that the facility failed to implement RD recommendations and physician orders for fortified diets, finger foods, and nutritional shakes, and failed to provide needed meal set-up and encouragement for two residents with severe cognitive impairment and documented significant weight loss. One resident, ordered a fortified diet and later finger foods due to roaming during meals, continued to receive standard plated meals without finger foods, had no care-plan updates, and was observed having trays placed without set-up assistance and removed uneaten without encouragement or alternative offerings. Another resident with dysphagia and a fortified mechanical soft diet, ordered high-calorie nutritional shakes twice daily after further weight loss, did not receive the shakes at breakfast or lunch, and staff removed largely uneaten trays without supervision, encouragement, or substitutions, while the DM and dietary staff acknowledged that RD recommendations and diet orders were not correctly reflected on meal cards or implemented.
Staff failed to administer and/or document physician-ordered nutritional supplement shakes for a cognitively intact resident on multiple days, with the MAR lacking entries for administration or refusal of the supplements. Leadership, including the administrator, DON, and ADON, stated that staff are required to document all administered or refused supplements and that monthly MAR/TAR reviews are expected, but the ADON reported that the February review was not completed due to covering additional MDS duties.
Failure to maintain hydration needs for a resident with paranoid schizophrenia, anxiety disorder, and BPH. The resident had a fluid restriction order that was later discontinued, but observations showed water placed out of reach while the resident remained in bed, called out for water, and stated being thirsty. Staff interviews confirmed the resident depended on staff for ADLs and often requested drinks, while the DON said staff were expected to offer fluids during care or when entering the room.
A resident with multiple comorbidities, severe cognitive impairment, dependence for ADLs, and an unstageable pressure ulcer experienced a significant weight loss of nearly 14% over two months. Facility policy required investigation and intervention for significant weight changes, but weights were not consistently documented, and no specific weight-loss interventions were added to the care plan. The RD identified increased nutrient needs, recommended supplements (Pro Heal, Juven) and later recommended adding Magic Cup BID, but this recommendation was not communicated to the physician, not entered as a diet order, and not provided with meals, as confirmed by observations and interviews with the resident, family, LPN, RD, and Dietary Manager. Leadership staff stated they expected RD recommendations to be reviewed and communicated, but this did not occur, resulting in failure to implement and evaluate appropriate nutritional interventions for the resident’s weight loss.
A resident with DM2, anemia, and a below-knee amputation had gradual weight loss while on a regular diet with Magic Cup supplements. Meal observations showed the resident ate some foods but inconsistently consumed the supplement, including one meal where staff did not remove the lid. Staff interviews showed CNAs and a CMT were unaware of weight-loss monitoring, the DON said there was no current meal intake process, and the resident's intake was not being consistently documented.
A resident with severe cognitive impairment, weakness, reduced mobility, encephalopathy, and type 2 DM was assessed by the RD as needing 2000 plus cc of fluids daily, but intake records showed repeated days below that amount. Surveyors observed the resident sitting for long periods in the day room, TV room, dining room, and activity room without drinks nearby, and staff did not consistently offer fluids even when checking blood glucose, moving the resident, or after toileting when the brief was dry and urine was dark and concentrated. Interviews confirmed the resident needed prompting to drink and that fluids should be offered at least every two hours.
A resident with vascular dementia and DM experienced severe weight loss while on hospice, but staff did not consistently document weights, did not update the care plan as diet orders changed, and did not notify the physician or RD when the resident became pale, gaunt, and appeared to be losing weight. The resident’s diet was changed multiple times from regular to puree, thickened liquids, snacks, shakes, and later back to regular and then puree again, yet the record showed no timely weight monitoring or communication about the 44.2-pound loss.
Failure to Provide Ordered Nutrition Support and RD Monitoring: A resident with renal disease and DM did not receive ordered double portions, a divided plate, or a sack lunch for dialysis days, and observations showed regular meals served without the ordered modifications. Two other residents had significant weight fluctuations, but there was no RD assessment or documentation that the DM/RD was notified. The DON and Administrator stated dietary assessments were to occur on admission, quarterly, annually, and with significant change, yet no dietary notes or assessments were in the record since 2024.
A resident with dementia, diabetes, kidney disease, and neurologic neglect syndrome had severe unplanned weight loss, dropping more than 15% of body weight in about three months. Staff did not fully notify the MD, DM, or RD, did not implement the RD’s increased TwoCal recommendation in the POS/MAR, did not document meal intake, and did not consistently provide assistance or encouragement during meals. During observation, the resident struggled to eat regular-textured food, left the dining room early, and ate less than 10% of the meal.
A resident with moderate cognitive impairment, malnutrition, Parkinson's disease, and heart failure had significant unplanned weight loss and orders for fortified foods and a Magic Cup. Staff did not consistently provide the ordered Super Cereal or Magic Cup, served corn flakes instead of the ordered fortified breakfast, and did not document missed intake or notify the nurse, physician, or RD when the prescribed diet was not consumed.
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