The 30-bed facility admitted Resident #31 on November 11 after he reported losing 45 pounds in three months. Hospital records showed he weighed 159 pounds on admission day. Staff never recorded his weight.
Two days later, his physician ordered weekly weigh-ins for four weeks, then monthly weights. Staff waited six days to put him on a scale.
By November 19, he weighed 148 pounds. Five days later, he had dropped to 145 pounds — a loss of 14 pounds since admission that no one documented until a dietician happened to notice.
The resident carried multiple diagnoses including acute respiratory failure, pneumonia, Parkinson's disease, a lung mass, muscle weakness, and difficulty swallowing. His admission assessment revealed severe cognitive impairment and a need for meal setup assistance.
When the dietician discovered the weight loss on November 24, she recommended nutritional supplements: a house shake twice daily, protein supplements, and frozen nutritional supplements to boost calories. She also upgraded his diet from mechanically soft food to regular texture with thickened liquids.
The doctor ordered the shakes and protein supplements that same day. But no order was written for the frozen supplements the dietician specifically recommended.
Staff gave him the prescribed supplements through his December 4 discharge date, medication records show. The frozen supplements never appeared.
Regional Clinical Registered Nurse #120 confirmed to inspectors that staff never weighed the resident on admission, violating both the physician's monitoring plan and facility policy.
The nurse revealed that staff had added the frozen supplements to the resident's meal ticket but never documented whether he actually received them. She told inspectors she would now require the dietitian to notify her directly about all nutritional communications.
Nobody weighed the resident again after November 24, despite the physician's order for weekly monitoring. He was discharged 10 days later with no record of whether his weight continued dropping.
The facility's own policies required staff to monitor residents for "undesirable or unintended weight loss" and weigh patients on admission and at intervals set by the care team. A separate nutrition protocol mandated that nursing staff "monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time."
Staff failed on both counts.
The resident had already reported intentional weight loss of 45 pounds over three months before his hospital stay. His admission with severe malnutrition, multiple respiratory problems, and swallowing difficulties should have triggered immediate and careful monitoring.
Instead, he entered the facility without a baseline weight, lost nearly 10 percent of his body weight in less than a week, and was discharged with gaps in both weighing and nutritional support.
The violation stemmed from a complaint investigation numbered 2677988. Federal inspectors classified it as causing minimal harm or potential for actual harm to residents.
For a facility serving 30 residents, many likely dealing with similar nutritional vulnerabilities, the breakdown in basic monitoring raises questions about how many other weight changes go unnoticed. The resident's 23-day stay ended with his discharge back to the community, his final weight unknown.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Care Center from 2025-12-23 including all violations, facility responses, and corrective action plans.