Mission at Alpine: Weight Loss Monitoring Fails - UT

The August inspection at Mission at Alpine Rehabilitation Center found that Resident 25's care plan specifically called for monitoring nutritional status and recording all intake. The plan, revised on July 15, stated: "Serve diet as ordered, monitor intake and record."

But when inspectors interviewed staff about the facility's 7 p.m. snack service, they discovered a gap in the very monitoring the care plan required.

Registered Nurse 2 told inspectors during an August 20 interview that while snacks were provided every evening at 7 p.m., "he did not think the snacks were documented."

The dietary manager confirmed that certified nursing assistants distributed the evening snacks. When asked what happened if residents missed the scheduled snack time, she said residents could request food later and that sandwiches were available in the refrigerator.

But the dietary manager couldn't answer basic questions about the process. She told inspectors "she could not answer what should be done about residents who missed the 7:00 PM snack and could not say if they were hungry or not."

The registered dietitian expressed concern about Resident 25's weight loss during a telephone interview with inspectors. She said she had received reports that the resident "was not eating well" and that the dietary manager "kept a close eye on the residents."

When asked about documentation of snack intake, the dietitian was uncertain. She told inspectors "she was unsure where snack intakes were documented but the nurses and CNAs paid attention to that."

The resident's care plan had been updated just over a month before the inspection, specifically addressing concerns about nutritional integrity related to recent surgery, incontinence, altered mobility, and impaired cognition. The plan was first initiated on June 17 and revised on July 15.

The approaches section of the care plan was explicit: "Monitor nutritional status. Serve diet as ordered, monitor intake and record."

Yet none of the staff interviewed could explain how evening snacks were being tracked for a resident whose weight loss had already triggered dietary concerns and a specific care plan requirement for intake monitoring.

The facility's evening snack program appeared to operate on an informal basis. While snacks were distributed daily at 7 p.m., and alternative food was available for residents who missed the scheduled time, the documentation that would allow staff to track whether at-risk residents were actually receiving adequate nutrition was missing.

For Resident 25, whose care plan specifically required monitoring and recording of all intake due to weight loss concerns, this documentation gap meant staff had no way to verify whether evening snacks were contributing to nutritional goals or if missed snacks were contributing to continued weight loss.

The registered dietitian's acknowledgment that she was receiving reports about the resident "not eating well" suggested ongoing nutritional concerns, making the lack of snack documentation particularly significant for tracking the resident's overall intake patterns.

The inspection found that while staff expressed awareness of the resident's weight loss and dietary concerns, the systems in place to monitor and document intake were insufficient to meet the requirements of the resident's individualized care plan.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Mission At Alpine Rehabilitation Center from 2025-08-20 including all violations, facility responses, and corrective action plans.

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