Health inspection·July 28, 2025

F692 §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. From 6/23/2025 to 6/27/2025, an unannounced visit was conducted at the facility for a recertification survey regarding unplanned insidious weight loss. The facility failed to ensure acceptable parameters of nutritional status were maintained for Resident 12 when Resident 12 experienced an unplanned insidious weight loss of 10 pounds, 6.8% in three months and 16 pounds 9.8% weight loss in six months. This had the potential to result in muscle wasting, loss of independence, decreased quality of life, and increased disease complications. A professional reference review of the National Library of Medicine titled, "An approach to the management of unintentional weight loss in elderly people," dated March 15, 2005, showed in part, "Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period ...Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred ...Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ "Involuntary weight loss can lead to muscle wasting... depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality." (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician). A publication titled "Nutrition Care of the Older Adult" from the Academy of Nutrition and Dietetics, dated 2016, indicated the goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight. A publication from the Academy of Nutrition and Dietetics titled "What Resources Are Available to Assist in Assessing Body Weight in Older Adults". July 1, 2025, indicated usual body weight (UBW), an individual's weight throughout adult life or a stable weight over time, is the preferred standard for older adults. Any recent weight changes, especially unintentional weight loss, would also need to be addressed in a care plan. UBW is considered more appropriate than desirable body weight or ideal body weight for weight-related interventions in older adults. During a review of the Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines (2007-2009), indicated the Registered Dietitian (RD) should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). The State Operations Manual (SOM) provides a definition for insidious weight loss: Gradual unintended weight loss over time is known as "insidious weight loss". This can be where an older adult loses only 1-2 pounds per month, but for a continued period. When addressing unintentional weight loss, one needs to figure out why, if possible, the root cause of unintended weight loss (Geriatric Dietitian, 3/31/22). Review of the facility Policy and Procedure (P&P) titled "Weight Assessment and Intervention" dated 2001, showed resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe; b. 3 months- 7.5 % weight loss is significant; greater than 7.5% is severe; c. 6 months - 10% weight loss is significant; greater than 10% is severe. Undesirable weight change is evaluated by the treatment team whether or not the criteria for "significant" weight change has been met. The evaluation includes but is not limited to the resident's target weight range and the resident's calorie, protein, and other nutrient needs compared with the resident's current intake and the relationship between current medical condition or clinical situation and recent fluctuations in weight; and whether and to what extent weight stabilization or improvement can be anticipated. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia (an eating disorder characterized by a restriction of food intake leading to low body weight), weight loss or increasing risk of weight loss. Interventions for undesirable weight loss are based on careful consideration of the following including but not limited to: Resident choice and preferences; nutrition and hydration needs; the use of supplementation. Review of the Admission Record (a document containing the most pertinent information for a resident) for Resident 12, indicated Resident 12 was 84 years old. Resident 12 was initially admitted on 1/17/2020 and readmitted on 3/27/25. Diagnoses included but were not limited to: acute chronic congestive heart failure (worsening of an existing heart failure symptoms), type 2 diabetes (a condition in which the body has trouble controlling blood sugar), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone which can disrupt things such as heart rate, body temperature, and metabolism), Alzheimer's disease (a progressive disease that destroys memory and other important functions), and dementia (a group of thinking and social symptoms that interfere with daily functioning). A record review of Minimum Data Set (MDS, an assessment used to plan care) "Section K - Swallowing/Nutritional Status" from 5/24/24 to 4/3/25 created for Resident 12 showed: 5/24/24 Quarterly Assessment: Weight 170 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 8/24/24: Quarterly Assessment: Weight 165 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 11/24/24 Quarterly Assessment: Weight 164 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 2/22/25 Annual Assessment: Weight 160 pounds, no weight loss or weight gain of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 3/12/25 Significant Change Assessment: Weight 158 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 3/21/25 Discharge Assessment: Weight 158 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 4/3/25 Readmission Assessment: Weight 154 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. During a record review of Resident 12's "Weights and Vitals Summary" from 4/3/24 to 6/23/24, the following monthly weights for Resident 12 were shown: 4/3/24: 175 lbs. 5/3/24: 163 lbs. (6.9 %, - 12 lb. weight loss in 30 days [comparison weight 4/3/24 175 lbs.]) 6/8/24 164.2 lbs. 7/12/24 167.2 lbs. 8/5/24 165 lbs. 9/2/24 164 lbs. 9/30/24 163 lbs. 11/11/24 164 lbs. 12/4/24: 164 lbs. 1/2/25: 162 lbs. 2/4/25: 160 lbs. 3/3/25: 158 lbs. 3/27/25: 154.6 lbs. 5/1/25: 154 lbs. 6/2/25: 148 lbs. Resident 12's documented weights represented an insidious loss in body weight of 16 pounds/9.8% from 12/4/24 to 6/2/24, and 10 pounds, 6.8% in three months from 3/3/25 to 6/2/25. A record review showed on 12/18/24, Resident 12 was prescribed Med Pass Sugar Free 90 ml, QD. (Med Pass Sugar Free is a nutrition supplement providing extra calories and protein and typically provided during the medication pass. It provides approximately 160 - 180 calories per 90 ml). RD recommended Med Pass to be discontinued on 2/20/25 due to resident refusals. The "Medication Administration Record [MAR]" dated 1/1/25-1/31/25 showed out of 31 days Resident 12 was offered Med Pass, he consumed 10% two (2) days, 20% one (1) day, 25% three (3) days, 50% four (4) days, and 100% 7 days. The MAR dated 2/1/25-2/28/25 showed out of the 21 days Resident 12 was offered Med Pass, he consumed 100% two (2) days, and 50% three (3) days. A record review of orders showed on 6/19/24 "Add snacks BID [twice a day], Document % intake". This order was discontinued on 3/24/24 and was not started again after readmission on 3/27/25. On 6/5/25, the RD recommended adding snacks BID. A record review showed Resident 12 was prescribed a No added Salt, Consistent Carbohydrate (CCHO; a diet typically prescribed to maintain blood sugar) diet from 6/8/24 to 3/27/25. A record review showed when Resident 12 was readmitted on 3/27/25, his diet order was a Cardiac - Low Fat Low Cholesterol, Low Salt, Diabetic No Concentrated Sweets (NCS) diet (a diet restricting foods and drinks with added sugars and simple carbohydrates; According to a progress note dated 6/5/25 RD recommended to change NCS diet to CCHO in house diet). A professional review titled, Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the America Diabetes Association, Diabetes Care 2016 showed, Liberal diets have been associated with improvement in food and beverage intake in the LTC population to better meet caloric and nutrient requirements. While carbohydrate intake should be taken into consideration, "no concentrated sweets" or "no sugar" diet orders are ineffective for glycemic management and should not be recommended. Instead, a consistent carbohydrate meal plan that allows for a wide variety of food choices may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes or type 2 diabetes on mealtime insulin. Review of the facility's 2023 "Diet Manual for Long Term Care Facilities" showed the CCHO diet provided 1900 - 2000 calories per day; and the Low Fat/Low Cholesterol Diet provided 1800 - 2000 calories per day. Calculations in accordance with the Diet Manual show a CCHO diet provided (the combination of a CCHO diet and Low Fat/Low Cholesterol may have provided fewer calories according to the diet manual): 1444- 2000 calories with an intake of 76-100%. 969 - 1500 calories with an intake of 51-75% 494 - 900 calories with an intake of 26-75% Review of Resident 12's record included a physician "Progress Note" dated 3/30/25, showed Resident 12 was transferred out on 3/21/25 for chest pain and was readmitted to the facility on 3/27/25. A record review from December 2024 to June 2025 showed the following RD Nutrition Progress Notes and Assessments: "Nutrition Assessment" dated 2/20/25 showed Resident 12's weight was 160 pounds, estimated caloric needs were 1818 - 2181 kcals (kilocalories, often referred to as calories), meal intake was 76-100% on average, supplement Med Pass Sugar Free 90 ml (milliliters) QD (every day), refusing Med Pass supplement on average. "No significant weight changes in the last 30, 90, and 180 days. PO intake is meeting ENN [estimated nutrition needs include caloric intake and protein intake]." RD's only recommendation in this assessment was to discontinue the nutritional supplement "Med Pass" due to the resident refusing the supplement. Although the RD documented Resident 12's intake was meeting his ENN in her 2/20/25 Nutrition Assessment, no additional interventions were implemented to address the insidious weight loss of 164 to 160 pounds from 12/4/24 to 2/25. While the RD documented in her 2/20/25 Nutrition Assessment, Resident 12's average meal intake was 76-100%, no time frame was specified. A record review of the Meal intake Documentation "Nutrition - Amount Eaten" for Resident 12, from 12/1/24 to 2/19/25, showed: from 12/21/24-12/31/24, Resident 12 consumed 76-100% for 62% of meals (56 out of 90 meals); from 1/1/25 to 1/31/25, Resident 12 consumed 76-100% for 59% of meals (54 out of 92 meals); and from 2/1/25 to 2/19/25, Resident 12 consumed 76-100 % for 58% of meals (32 out of 55 meals). "Progress Note" dated 3/20/25 showed Resident 12 weighed 158 pounds, average meal intake was 84%, average snack intake was 50%. " ... No significant weight changes in the last 30, 90, 180 days. PO (by mouth) intake meeting ENN ... no new recommendations at this time ..." Although the RD stated Resident 12 was meeting his ENN in her 3/20/25 progress note, Resident 12 experienced an insidious weight loss of 6 pounds between 12/4/24 and 3/3/25. While RD documented in her 3/20/25 progress note, Resident 12's average meal intake was 84%, no time frame was specified. A record review of the Meal intake Documentation "Nutrition - Amount Eaten" for Resident 12, from 2/21/25 to 3/19/25 (dates between RD nutrition assessment on 2/20/25 and RD progress note on 3/20/25), showed: from 2/21/25-2/28/25, Resident 12 consumed 76-100% for 67% of meals (16 out of 28 meals); and from 3/1/25 to 3/19/25; Resident 12 consumed 76-1 00% for 48% of meals (25 out of 52 meals). The "Nutrition Assessment" dated 4/3/25 showed Resident 12 weighed 154 pounds, estimated caloric needs were 1750 - 2100, average meal intake was 50-75%, and no supplements. "PO intake meeting ENN. No new recommendations at this time." While RD documented Resident 12's intake was meeting ENN in her 4/3/35 Nutrition Assessment, calculations including percentage intake and calories provided by the diet manual showed Resident 12 did not meet ENN. RD stated Resident 12's average meal intake was 50-75%, but no time frame was specified. RD did not show how many calories 50-75% intake provided. According to the diet manual 50-75% intake of a CCHO diet provided 969-1500 calories which did not meet Resident 12's ENN of 1750-2100 calories per RD's assessment dated 4/3/25. Resident 12 experienced insidious weight loss of 9.4 pounds between 12/4/24 and 3/27/25. "Progress Note" dated 6/5/25, showed " Weight changes: -3.9%/-6# x 30 days, -6.3%/-10# x 90 days, -9.8%/-16# x 180 days ... 84 year old male noted with significant weight loss of -6 # [pounds] x 30 days ... Weight loss is undesirable as resident is meeting only 93% of IBW [Ideal Body Weight] ... Resident may benefit from resuming snacks BID to increase calorie and protein intake and monitor on weekly weights x 4 weeks." RD did not recommend interventions to address weight loss until Resident 12 experienced an unplanned weight loss of 6 pounds between 5/1/25 and 6/2/25, 10 pounds between 3/3/25 and 6/2/25, and 16 pounds between 12/4/24 and 6/2/25. During a concurrent phone interview and record review with Registered Dietitian (RD) on 6/25/25 at 9:53 a.m., Resident 12's weight log, progress notes, assessments, and physicians' orders from 3/5/2024 to present, were re