Signature Health Portland: Weight Loss Monitoring Fails - TN
Federal inspectors found that Signature Health of Portland Rehab & Wellness Center failed to follow its own weight monitoring protocols for at least one resident, with no documentation from the registered dietitian in February after weight loss was identified, and none in March either.
The facility's Director of Nursing confirmed during a September 9 interview that residents should be seen by the registered dietitian when they experience five percent weight loss in 30 days. She verified there was no dietitian documentation in February after the weight loss had been identified, and no documentation in March.
Staff interviews revealed confusion about basic monitoring procedures. Licensed Practical Nurse H, who served as a floor nurse, told inspectors that residents should be weighed on admission, weekly for two weeks, then monthly. If weight problems were identified, she said, they would be reported to management and physicians.
The facility's State Care Consultant said residents should be weighed on admission and weekly for two weeks, then "monitored per policy." But when inspectors interviewed the former registered dietitian, RD L, she was familiar with the resident's name but could not recall any details related to the weight loss.
CNA C told inspectors she would notify nurses when residents didn't eat well and would try to help them eat. She said when residents consumed less than 50 percent of meals, they were offered snacks, and facility staff distributed snacks to residents at least twice daily.
The Director of Nursing explained that she monitors weight loss and discusses cases at weekly "At Risk" meetings held every Thursday. These meetings include clinical leadership, the Director of Nursing, Assistant Director of Nursing, Social Service Director, and Activities Director.
She said the current registered dietitian, RD J, has been kept updated with residents' weights and visits the facility every Monday, since the facility doesn't have a dietitian on staff full-time.
A Physical Therapy Assistant who served as backup to the rehabilitation manager confirmed that the affected resident was receiving speech therapy services during the time period in question.
The facility's CNAs told inspectors they document meal percentages in electronic medical records and report when residents eat less than half their meals. But the systematic breakdown occurred at the dietitian level, where required interventions never materialized despite documented weight loss.
Federal regulations require nursing homes to maintain comprehensive nutritional care programs, including prompt identification and treatment of residents at risk for malnutrition. The inspection found the facility failed to ensure proper dietitian involvement when a resident met the criteria for intervention.
The Director of Nursing's admission that no dietitian documentation existed for two consecutive months after identifying significant weight loss demonstrates a clear gap between the facility's stated policies and actual practice.
This violation received a "Level of Harm - Actual harm" designation, meaning inspectors determined the facility's failure to monitor weight loss properly caused actual harm to the resident involved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Health of Portland Rehab & Wellness Cent from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT in PORTLAND, TN was cited for violations during a health inspection on September 11, 2025.
She verified there was no dietitian documentation in February after the weight loss had been identified, and no documentation in March.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.