Health inspection·October 29, 2025

72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (c) Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his or her professional licensure. 72315 (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. 483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- 483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; 483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; 483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. On 8/5/25, an unannounced visit was conducted at the facility to investigate a re-certification survey. Resident 4 was identified as having inappropriate and delayed nutritional interventions and monitoring. Resident 4 sustained a 9.58% weight loss from 5/30/25 to 6/27/25 and a continued total weight loss of 14.37% from 5/30/25 to 7/17/25, which resulted in an overall weight loss of 11.98% from admission on 5/30/25 to 7/31/25. The facility failed to: 1. Ensure treatment and care in accordance with professional standards of practice was provided when Resident 4, who had protein-calorie malnourishment on admission was not placed on a therapeutic diet type or provided therapeutic diet nourishments for her diagnosis when admitted. 2. Ensure good nutrition and individual patient care plans were provided when Resident 4, who sustained a 9.58% weight loss from 5/30/25 to 6/27/25 and had variable and poor oral intake, was provided an inappropriate nutritional intervention of snacks between meal on 7/1/25. 3. Ensure maintenance of acceptable parameters of nutritional status when Resident 4, who sustained a 14.37% weight loss from 5/30/25 to 7/17/25 did not have a therapeutic diet type and therapeutic diet nourishment initiated into her plan of care until 7/18/25. 4. Ensure identification of care needs when Resident 4's weekly weights were not compared or trended in comparison to previous week's weights or admission weights. 5. Ensure identification of care needs from health professionals involved in the care of the resident when Resident 4, who had documented unintentional weight loss did not have the provider in attendance to IDT (interdisciplinary team) Weight Management Assessment and IDT Weight Management Update meetings. 6. Ensure care needs were met based upon continuing assessments when Resident 4, who was admitted from 5/30/25 to the time of the unannounced survey exit on 8/14/25 had not been assessed in person by the Registered Dietician as she was remote based and had not seen Resident 4, but was completing assessments and recommendations. 7. Ensure facility weight loss and monitoring policies and procedures were followed. These failures resulted in a delay in acting on Resident 4's weight loss, delayed treatment and care and contributed to a severe weight loss ( severe weight loss as defined by the facility's policy and procedure titled, "Weight Assessment and Intervention," dated 3/2022,"...the threshold for significant unplanned and undesired weight loss will be based on the following criteria....1 month - 5% weight loss is significant; greater than 5% is severe... 3 months - 7.5% weight loss is significant; greater than 7.5% is severe...6 months- 10% weight loss is significant; greater than 10% is severe...") of 9.58% from 5/30/25 to 6/27/25 and a continued total weight loss of 14.37% from 5/30/25 to 7/17/25. Resident 4 was an 80-year-old female, admitted to the facility on 5/30/25. She had diagnoses that included protein-calorie malnourishment (condition where the body does not receive enough protein and/or calorie from food which can lead to worsening of nutritional status), type 2 diabetes (high blood sugar), iron deficiency (condition where the body lacks enough iron to produce red blood cells), dysphagia (trouble swallowing), chronic kidney disease progressive damage to kidneys and cannot filter blood adequately), and dementia (progressive decline in memory and cognition). Resident 4 had severely impaired thinking ability and memory. During a review of Resident 4's "Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information)", dated 8/12/25, the "AR" indicated Resident 4 was admitted to the facility on 5/30/25 with diagnoses of type 2 diabetes (T2DM-high blood sugar), protein-calorie malnutrition (PEM-inadequate intake of protein and calories), iron deficiency (body lacks sufficient iron), chronic kidney disease (CKD-progressive damage to kidneys and cannot filter blood adequately), dementia (progressive decline in memory and cognition), and altered mental status. During a review of Resident 4's "Minimum Data Set" (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment)", dated 6/2/25, the "MDS" indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) score of 7 out of 15, which indicated Resident 4 was severely cognitively impaired. During a review of Resident 4's "MDS", dated 6/6/25, the "MDS" indicated Resident 4 had a Swallowing and Nutritional Status (a resident assessment tool used to identify resident's ability to maintain adequate nutrition and hydration, covering aspects like swallowing disorders, height, weight, weight loss, and nutritional approaches) assessment completed on admission with no identified swallowing or nutritional issues. During a review of Resident 4's "Weights and Vitals Summary," dated 8/12/25, the document indicated, Resident 4's weights were "...5/30/2025 167 lbs (pounds- a unit of weight measurement)....6/6/2025 167 lbs...6/12/2025 164 lbs...6/19/2025 161 lbs...6/27/25 151 lbs...7/3/2025 149 lbs...7/10/2025 149 lbs...7/17/2025 143 lbs...7/24/2025 146 lbs...7/31/25 147 lbs..." The document indicated Resident 4 had a 9.58 % weight loss in one month, from 5/30/25-6/27/25. The document indicated Resident 4 had a 14.37% weight loss in one and a half months, from 5/30/25-7/17/25. The document indicated Resident 4 had a 11.98% total weight loss from admission on 5/30/25 to the most recent weight on 7/31/25. The document did not give any indication that the facility predicted, anticipated or implemented timely or appropriate diet type interventions or identify potential nourishment factors that could lead to unintentional weight loss on admission or on the first signs of weight loss. During a review of Resident 4's "Order Summary Report," dated 8/13/25, the document indicated, from 5/30/25-6/2/25 Resident 4 had a regular diet pureed texture thin consistency, from 6/2/25-6/9/25 Resident 4 had a regular diet minced and moist thin consistency, from 6/9/25-7/18/25 Resident had a regular diet mechanical soft texture thin consistency, from 7/18/25-8/7/25 Resident 4 had a fortified/high protein diet mechanical soft texture consistency to promote weight maintenance, and from 8/7/25- 8/13/25 Resident 4 had a fortified/high protein diet mechanical soft texture thin consistency. The document indicated Resident 4 had a 9.58% weight loss from 5/30/25-6/27/25 and on 7/1/25 diabetic snacks (healthy snacks that are low in added sugar) were added three times a day, in between meals related to significant weight loss and variable oral intake. The document indicated Resident 4 had a 14.37% weight loss from 5/30/25-7/17/25 and on 7/18/25 a fortified/high protein diet to promote weight maintenance and high protein nourishment two times a day were added for increased protein needs, on 7/21/25 additional snacks were added three times a day in between meals to promote increased oral intake. During a review of Resident 4's "Nutrition Assessment," dated 6/16/25, the document indicated Resident 4 had a 51%-75% intake for food and fluid. The document indicated Resident 4 had variable oral intake and was at risk for malnutrition due to her diagnosis of protein-calorie malnourishment. The document indicated Resident 4 required, "...caloric needs...CBW [current body weight]: 164lb, 74.5 kg [kilogram- a unit of weight measurement] 1490-1863 (20-25 kcal[kilocalorie- practical energy unit needed for human consumption]/kg/CBW)...protein needs...75-82 gm 1.0-1.1 gm/kg/CBW..." During a review of Resident 4's "IDT (interdisciplinary team) Weight Management Assessment," dated 6/27/25, the document indicated, Resident 4 had a significant weight loss in one week. The document indicated, "...weight change likely [related to] variable [oral] intakes...resident would benefit from weight maintenance/no further weight loss at this time... " Dietary recommendations included adding diabetic snacks three times a day and to continue weekly weights. The document was signed by the Registered Dietician (RD). The document did not indicate the provider was in attendance. There was no documentation to indicate how much of the snacks the resident consumed once they were initiated, only documentation if a snack was given. During a review of Resident 4's "IDT Weight Management Update," dated 7/3/25, the document indicated, "...weight update...weights: 07/03/2025: 149 lbs 06/27/2025: 151 lbs 06/19/2025 161 lbs weight change:18 lb (-10.7%) x1/mo [one month]...meal consumption: 25-50%...Resident's current weight on 07/03/2025 in 149 lbs, reflecting a continued downward trend from 151 lbs on 06/27/2025 and 161 lbs on 06/19/2025....meal consumption remains variable, ranging between 25-50%. Resident is receiving 2 pm snack due to risk for malnutrition. Due to recent significant weight loss and inconsistent PO intake, dietary plan has been updated to included diabetic (DM-diabetic) snacks three times daily between meals...." The document was signed by the RD. The document did not indicate an order for a 2 p.m. snack was placed. The document did not indicate the provider was in attendance. There were no additional interventions initiated at this time. During a review of Resident 4's "IDT Weight Management Update," dated 7/18/25, the document indicated, "...weight update...weight variance...143lb...weight change 6 lb (-4%) x1/wk [one week]...weight change likely [related to] variable PO intake. Resident with continued care presenting with significant weight loss x >3 month [greater than 3 months]...resident would benefit from no further weight loss at this time...add fortified/high protein diet...add HPN [high protein] BID [twice a day]..." The document was signed by the RD. The document did not indicate the provider was in attendance. During a review of Resident 4's "IDT Weight Management Update," dated 7/24/25, the document indicated, "...most recent weight on 07/24/2025 is 146 lbs, up from 143 lbs on 07/17/2025, and down from 149 lbs on 07/10/2025...resident has exhibited a pattern of gradual weight loss for over three months...continue to monitor trends..." The document was signed by the RD. The document indicated Resident 4 had lost twenty-one pounds since admission on 5/30/25. The document indicated once a high protein fortified diet and high protein nourishment shake were added on 7/18/25 Resident 4's weight improved. The document indicated Resident 4 was admitted with a protein calorie malnourishment and poor variable intake. The document indicated dietary inappropriately added snacks as a first intervention for a resident with decreased and variable intake. The document indicated Resident 4 was not appropriate assessed for nutritional needs. The document did not indicate the provider was in attendance. During a review of Resident 4's "IDT Weight Management Update," dated 7/31/25, the document indicated, "...weight update...weights: 07/30/2025: 147 lbs 07/24/2025: 146 lbs 07/17/2025: 143 lbs 07/10/2025: 149 lbs...will changed resident from weekly weights to monthly weights..." The document was signed by the RD. The document did not indicate the provider was in attendance. The document did not trend the weight to the admission weight. During an interview on 8/8/25 at 11:10 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 4 did not have swallowing or chewing difficulties. CNA 2 stated she was not aware of any swallowing or nutritional concerns for Resident 4. CNA 2 stated Resident 4 needed minimal assistance and ate meals in her room independently. During an interview on 8/8/25 at 11:15 a.m. with the Responsible Party (RP) 2, RP 2 stated he was Resident 4's husband. RP 2 stated he visited Resident 4 every day. RP 2 stated some days Resident 4 did not eat a lot. RP 2 stated facility staff weighed her frequently throughout the month. RP 2 stated he was not aware of her current weights or weight trend. During a concurrent interview and record review on 8/12/25 at 10:57 a.m. with the Speech Language Pathologist (SLP), Resident 4's "Electronic Medical Record," dated 8/12/25 was reviewed. The SLP stated Resident 4 had been placed on his service since admission related to dysphagia and memory care. The SLP stated he had been working with Resident 4 to develop strategies and recall techniques to determine her least restrictive diet texture and encourage oral intake. The SLP stated Resident 4 did not currently have any swallowing or chewing issues. The SLP stated Resident 4 required encouragement with meal intake. The SLP stated he spoke with staff and had recommended meal encouragement when eating and distant supervision by eating in the vintage dining hall (the title of a designated dining hall within the facility where residents were brought to dine with staff supervision). The SLP stated there was no specific documentation of the recommendation or order for meal encouragement and dining in the vintage dining hall for distant supervision . The SLP stated he had changed Resident 4's diet texture throughout admission to determine the least restrictive diet texture and the Registered Dietician (RD) was responsible to determine the most appropriate diet type. The SLP stated dietary and clinical staff would refer residents to him for weight loss if there was a concern for swallowing or chewing. The SLP stated he had not received a weight loss referral for Resident 4. The SLP stated Resident 4 had a diet type order change on 7/18/25 to a fortified/high protein diet. The SLP stated from 5/30/25-6/27/25 Resident 4 had lost over 10 lbs, which was considered a significant weight loss. The SLP stated he had been aware of Resident 4's weight loss. The SLP stated a fortified/high protein diet should have been started immediately on admission or with noted significant weight loss. The SLP