Failure to Provide Ordered Vegetarian Diet, Address Significant Weight Loss, and Serve Breakfast on Dialysis Days
Summary
The deficiency involves the facility’s failure to meet residents’ nutritional needs by not honoring a prescribed vegetarian diet and not responding to significant weight loss for one resident, and by not providing breakfast meals on dialysis days for another resident. One resident with diabetes mellitus was admitted for IV antibiotic therapy after a recent UTI and was identified as at risk for dehydration and nutritional issues. Her baseline care plan and physician orders documented a vegetarian diet, regular texture, and thin liquids, and the care plan instructed staff to monitor and record meal intakes, obtain RD evaluation as needed, and complete weekly weights. Despite this, her MDS showed she did not receive a therapeutic diet, and her meal tickets were printed as a regular diet with meat-based options such as chicken, cheeseburger, hot dog, and sloppy joe, and no vegetarian menu was available. Dietary staff acknowledged they did not have a vegetarian meal ticket for her and had not yet ordered soy burgers, and staff reported difficulty providing her vegetarian diet due to lack of appropriate choices. The same resident’s intake of facility-provided meals was documented as poor, less than 50% of meals, and she was described as very particular about what she ate, with her husband frequently bringing in outside food of unknown amounts. Weights documented in the EMR showed 156.2 lbs on admission and again on a later date, followed by a drop to 132.8 lbs and then a calculated weight of 128.4 lbs when the wheelchair weight was subtracted, representing a significant weight loss of 16.3% in 19 days. The EMR lacked a progress note addressing the weight loss on the date it was first recorded, and nursing documentation showed that when the provider was in the facility shortly after the low weight was obtained, staff updated the provider about low blood pressure but not about the weight loss. The provider was not documented as being notified of the weight loss until several days later, and there was no evidence of re-weighing, appetite stimulant orders, or nutritional supplements being initiated despite existing orders allowing the RD or interdisciplinary team to start supplements. Administrative and dietary staff later reported they were unaware of the weight loss at the time and had not reviewed the resident’s weights. The deficiency also includes failure to provide breakfast meals to another resident with ESRD and moderate protein-calorie malnutrition who received dialysis three times per week. This resident had a therapeutic renal dialysis diet ordered and required set-up assistance for eating, with documentation that his meal intakes were generally good and adequate to meet estimated needs. His EMR showed multiple breakfast meal entries on dialysis days marked as “not available” or “not applicable,” and staff interviews revealed that he left very early for dialysis and was not provided breakfast or a snack to take with him. The resident reported he did not eat breakfast before dialysis because none was provided, and he did not receive a snack at the dialysis center. CNAs and an LN confirmed that no actual breakfast meal was prepared for him on dialysis mornings, the kitchen was closed at the time he woke up, and no alternative food or drinks were offered to take with him. The facility’s own policies on dialysis care and frequency of meals required communication about nutritional management and provision of at least three meals daily at regular times or according to resident needs and care plan, but these were not followed for this resident on dialysis days. The facility’s Nutrition (Impaired)/Unplanned Weight Loss clinical protocol required monitoring and documenting weight and dietary intake in a way that allowed ready comparison over time, defining current nutritional status through interdisciplinary assessment, and using supplementation strategies such as food fortification and increased portions for residents with impaired nutrition or risk factors. For the resident with significant weight loss and a vegetarian diet order, the record and interviews showed that although poor intake and vegetarian preference were known, the facility did not adjust menus to provide appropriate vegetarian options, did not consistently document or act on poor intake, and did not promptly assess or intervene when substantial weight loss occurred. For the resident on dialysis, the facility’s Dialysis, Care for a Resident policy required communication about nutritional and fluid management, and the Frequency of Meals policy required at least three meals or their equivalent daily, but staff acknowledged that no breakfast meal or equivalent was prepared or offered on dialysis mornings, and refusals were not documented in the EMR or care plan.
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.
Two residents with dysphagia and complex nutritional needs experienced significant weight loss, but staff did not promptly notify the physician or implement timely interventions. One resident with Type 2 DM lost over 7% of body weight within a month without documented physician notification or immediate adjustment of nutritional supplements. Another resident was not weighed on readmission, showed a nearly 10% loss when first weighed, and had inconsistent administration of ordered supplements due to unavailability and later discontinuation, despite documented severe malnutrition and high nutrition risk. The RD confirmed that physicians were not notified when the significant weight losses were identified and that interventions were delayed.
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.
Failure to Notify Physician and Implement Timely Interventions for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely recognition and response to significant weight loss for two residents, including lack of physician notification and delayed nutritional interventions. One resident with diagnoses of dysphagia, oropharyngeal phase, and Type 2 DM had a documented weight of 151.9 pounds in early December and 140.9 pounds in early January, representing a 7.2% weight loss in 27 days. Despite this significant weight loss, there was no documented evidence that the physician was notified at the time the loss was identified, and no intervention was documented until early March, when the resident’s Boost Breeze supplement was increased from twice daily to three times daily. For the second resident, who also had dysphagia, oropharyngeal phase, the facility used a hospital weight of 88 pounds at readmission and did not obtain an actual weight on the day of readmission. The first in‑facility weight, taken three days later, was 79.5 pounds, reflecting a 9.7% loss from the hospital weight in three days. There was no documented evidence that the physician was notified of this significant weight loss when it was identified. The RD’s nutritional monitoring note several days later documented the weight decline, underweight BMI, variable oral intake, pureed diet with thin liquids, and ordered supplements (Boost BID and Magic Cup daily) to support caloric intake, and identified the resident as at high nutritional risk with a diagnosis of severe malnutrition. Record review of the second resident’s MAR showed that the ordered supplements were not consistently provided. The Magic Cup was not administered on multiple mornings due to “drug/item unavailable,” and Boost 8 oz BID was also not administered on several dates for the same reason. The RD later confirmed that the supplements were discontinued due to the resident’s refusal. The RD also confirmed that for both residents, the physicians were not notified of the significant weight losses and that interventions were not put in place at the time the weight losses were identified. The facility therefore did not ensure timely physician notification and implementation of interventions in response to significant weight loss for these residents.
Plan Of Correction
F 06921. On 4/30/26 the MD was made aware of significant weight losses for R 27 and R 83. Dietitian reviewed R 27 and R83, all interventions reviewed and approved by MD. 2. All resident who have experienced significant weight loss have the potential to be affected, the Dietitian/designee completed a 30 day look back to ensure that all identified significant weight losses had and intervention in place and both weight loss and intervention had been notified to the MD and were reflected in the EHR. Where applicable the notification was completed. 3. To prevent the potential for reoccurrence, the NHA/designee re-educated the IDT team on the facility weight process with an emphasis on timely provider notification of significant weight loss and implementation of interventions. 4. To monitor and maintain ongoing compliance, the DON/designee will audit residents' weights x 4 weeks, then monthly x2 to ensure any significant weight loss is communicated in a timely manner to the MD with an intervention and documented in the HER. The results of the audit will be forwarded to the facility QAPI committee monthly for further review and recommendations as needed.
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