CENTER, MO - A May 2025 inspection at Westview Nursing Home revealed concerning gaps in nutritional monitoring after staff failed to document a resident's food intake despite weight loss and increased appetite, raising questions about the facility's meal supervision protocols.
Critical Nutritional Monitoring Failures
The inspection uncovered a significant breakdown in basic nutritional care when staff at the 301 West Dunlop Street facility failed to monitor and document a resident's meal intake, even as the individual experienced weight loss and requested larger portions. The resident, who had been asking for double portions due to persistent hunger after meals, did not receive adequate monitoring of their nutritional status.
Medical records showed no documentation of the resident's oral intake from meals on the day of inspection, May 21, 2025. This oversight occurred despite nursing assistants reporting that the resident required "more assistance with eating lately" and "a lot more assistance with eating recently," according to staff interviews conducted during the inspection.
The resident's situation became more concerning when the registered dietician revealed during her 2:00 P.M. interview that she was "just now seeing the resident's current weight loss" because the previous month's review had not flagged any weight concerns. In fact, the resident had initially appeared to trigger for weight gain the previous month, leading to confusion about the accuracy of weight measurements.
Systemic Communication Breakdowns
The inspection revealed a troubling pattern of communication failures within the facility's nutritional care system. The registered dietician explained that staff were experiencing difficulties because the resident wanted regular food while being prescribed a mechanical soft diet, necessitating work on a diet waiver to address the resident's preferences and nutritional needs.
To address the apparent nutritional deficiency, the facility had started the resident on Boost supplements three times daily beginning May 7, 2025. However, the dietician indicated she would need to examine the resident's percentage of intake and determine whether double portions would be appropriate - highlighting how basic nutritional assessment had been delayed.
The most revealing aspect of the investigation came during the Assistant Director of Nursing's interview on June 5, 2025. She explained that meal intake documentation was "completed as needed" but required the Director of Nursing to trigger the task for certified nurse assistants to complete. The critical failure occurred because "the previous DON never triggered the task for the CNAs to chart" the resident's meal intake.
Medical Significance of Nutritional Monitoring
Proper nutritional monitoring in long-term care facilities serves as a critical early warning system for detecting health deterioration. When residents experience weight loss or changes in appetite, these indicators can signal underlying medical conditions, medication side effects, or the progression of existing health problems. Inadequate caloric intake in elderly residents can lead to muscle wasting, decreased immune function, and increased risk of infections.
The failure to document food intake becomes particularly concerning when residents are already experiencing weight fluctuations. Medical protocols require systematic tracking of nutritional status because malnutrition in elderly residents can develop rapidly and contribute to falls, delayed wound healing, and increased mortality risk. Regular monitoring allows healthcare teams to intervene promptly with dietary modifications, supplements, or medical evaluations.
The mechanical soft diet prescribed for this resident indicates potential swallowing difficulties or other medical conditions requiring modified food textures. When such residents request regular food, proper protocols demand immediate assessment by dietary and nursing staff to ensure safe swallowing while meeting nutritional needs and patient preferences.
Standard Care Protocols Not Followed
Industry standards require nursing facilities to maintain comprehensive nutritional assessment programs that include regular monitoring of food and fluid intake, especially for residents with identified risk factors. The Centers for Medicare & Medicaid Services regulations mandate that facilities ensure residents receive adequate nutrition and hydration, with systematic documentation serving as evidence of compliance.
Proper protocols would have required immediate implementation of intake monitoring when the resident began requesting double portions and expressing continued hunger. The facility should have conducted a comprehensive nutritional assessment, consulted with the dietician promptly, and adjusted the care plan accordingly. Additionally, any changes in a resident's eating patterns or assistance needs should trigger immediate documentation and review.
The communication breakdown between the Director of Nursing and frontline staff represents a systemic failure in the facility's quality assurance processes. Effective nutritional care requires coordinated effort between nursing staff, dietary personnel, and medical providers, with clear protocols for initiating and maintaining monitoring systems.
Administrative Response and Ongoing Care
The Administrator confirmed during the May 21, 2025 interview that staff were responsible for assisting residents who needed help with eating, acknowledging the facility's obligation to provide adequate support. However, the inspection revealed that despite this stated policy, the actual implementation of nutritional monitoring had failed due to administrative oversight.
The resident's case highlights broader concerns about staff communication and supervisory oversight within the facility. The gap between the previous Director of Nursing's departure and the implementation of proper monitoring protocols created a vulnerable period where essential care documentation was not maintained.
Additional Issues Identified
The inspection also documented concerns about the accuracy of weight measurements, with staff expressing uncertainty about previous weight readings that had initially suggested weight gain rather than loss. This measurement inconsistency further complicated the facility's ability to assess the resident's nutritional status accurately and implement appropriate interventions in a timely manner.
The delayed recognition of the resident's weight loss, combined with the absence of intake monitoring, represents multiple points of failure in the facility's nutritional care system that required immediate correction to prevent potential health complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westview Nursing Home from 2025-05-21 including all violations, facility responses, and corrective action plans.
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