Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents' weights were adequately monitored and that appropriate follow-up actions were taken in response to significant weight changes for two residents. One resident, admitted with diagnoses including a thoracic vertebrae fracture, type 2 diabetes, and malnutrition, had a care plan indicating a nutritional problem and an intervention to obtain weights as ordered. Despite a physician's order for monthly weights, the resident experienced a weight loss from 105.4 lbs to 96.0 lbs over two months, representing a 6.61% decrease. There was no documented evidence of a reweigh or a nutritional assessment in response to this significant weight change. Another resident, admitted with conditions such as osteoarthritis, hyperlipidemia, type 2 diabetes, and other complications, also had a care plan for nutritional monitoring and a registered dietician evaluation as needed. This resident's weight dropped from 219 lbs to 203.6 lbs, a 7.6% decrease, without any documented reweigh or nutritional assessment following the significant weight loss. These findings were based on clinical record reviews and staff interviews, indicating a failure to follow established resident care policies and nursing services requirements.