§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-
§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;
§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;
§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
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Observations:
Based on select facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to consistently assess, monitor, and respond to significant weight changes to identify nutritional risks and implement timely nutritional interventions for three of twenty-four residents reviewed (Residents 1, 41, and 28).
Findings include:
A review of a policy entitled "Weight Change Monitoring and Management Policy" last reviewed January 1, 2026, indicated that a systematic process for identifying, assessing, and documenting, and addressing significant weight changes in residents to promote optional nutritional status, recent avoidable weight loss or gain, and ensure compliance with federal and state regulations. The facility shall monitor resident weights routinely and promptly investigate significant weight changes. Residents experiencing clinically significant weight loss or gain will receive interdisciplinary assessment and intervention. Significant weights changes are considered clinically significant based on a 5 percent change within thirty days, 7.5 percent change in ninety days, and 10 percent change in one-hundred and eighty days. A significant weight change triggers a verification of weight accuracy with a reweight obtained within twenty-four to forty-eight hours, a review of intake records, edema assessment, medication review, physician notification, and/or interdisciplinary review. Assessment includes nutritional intake patterns, functional abilities, swallowing function, behavioral factors, psychosocial issues, medical diagnosis, medication effects, and hydration status. The nutrition interventions include dietary consultation, nutritional supplements, food preferences, adaptive equipment, speech evaluation, meal environment modification, medication adjustment, and/or physician evaluation. Care planning includes care plan and review and revision, resident and family involvement as appropriate, measurable interventions and goals, and on-going monitoring.
A review of the facility policy entitled "Weighing and Measuring a Resident," last reviewed by the facility on January 1, 2026, indicated that a reweight was to be obtained within twenty-four to forty-eight hours when a resident had a 5 percent weight change in one month, a 5 pound change from the previous weight, or a 3 pound weight loss when the resident weighed one hundred pounds or less. The policy indicated that resident weights were reviewed weekly by the Registered Dietitian, and significant weight losses or gains were reported during the weekly Risk Meeting. The policy indicated that the Registered Dietitian communicated the need for additional weights to nursing administration. The policy indicated that the physician and family were to be notified of significant weight loss or gain, refusal of meals, and failure of interventions. The policy defined unplanned and undesired weight loss as significant when a resident lost 5 percent of body weight in one month, 7.5 percent in three months, or 10 percent in six months. The policy defined weight loss as severe when the loss was greater than 5 percent in one month, greater than 7.5 percent in three months, or greater than 10 percent in six months.
A clinical record review revealed Resident 1 was admitted to the facility on July 19, 2023, with diagnoses that included dementia (a brain disorder that slowly destroys a person's memory and thinking skills and characterized by a loss of cognitive functioning such as thinking, remembering, and reasoning that interfere with a person's daily life and activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and feeding difficulties (problems that interfere with the ability to eat or drink safely and effectively, often involving multiple stages of the feeding process such as choosing and getting food to the mouth, chewing, and swallowing).
A review of Resident 1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 21, 2026, revealed that Resident 1 had moderate cognitive impairment with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment) and able to eat independently after staff set-up.
A plan of care review revealed a nutrition at risk care plan was initiated on June 19, 2023, identified that Resident 1 had nutritional problems or potential for nutritional problem related to a medical need for a therapeutic diet, feeding difficulties, poor vision and hearing deficits, and history of significant weight loss with goals to maintain adequate nutritional status as evidence by maintaining weight and no signs or symptoms of malnutrition. Planned interventions included to monitor weight and report changes to the physician and Registered Dietitian (RD), provide and serve diet and supplements as ordered, monitor and record meal intakes for each meal, quarterly and PRN (as needed) nutrition assessments, and RD to evaluate and make changes and recommendations PRN.
A clinical record review revealed that the most recent comprehensive nutrition assessment for Resident 1 was last completed on October 25, 2024, and no comprehensive nutrition assessments completed by a RD during 2025. Resident 1's clinical record failed to reveal that a comprehensive nutritional assessment was completed annually as required.
A clinical record review revealed a late-entry quarterly nutrition/dietary note completed by Employee 4, the facility's former Registered Dietitian (RD), with an effective date of January 21, 2026, at 9:47 AM, and a creation date of February 26, 2026, at 9:56 AM. The note documented that Resident 1 continued a no-added-salt diet (a diet that limits added salt by omitting table salt and salt packets), regular food texture, and thin liquids. The note further documented that the resident required varying levels of assistance with meals, primarily set-up assistance and assistance cutting food. According to the note, the resident had adequate fluid intake and consumed between fifty percent and one hundred percent of meals during the previous thirty days.
The note further documented the resident utilized adaptive dining equipment, including a Kennedy cup (a spill-resistant drinking cup) and an inner-lip plate (a plate with a raised edge designed to assist with self-feeding). The documented weight history reflected a current body weight of 139.8 pounds on January 2, 2026, compared to 140.4 pounds on December 2, 2025, 134.3 pounds on October 2, 2025, and 134.9 pounds on July 5, 2025. Employee 4 documented that the resident had no significant weight changes and maintained a relatively stable weight over the previous six months.
However, a review of Resident 1's weight record revealed the resident weighed 144.2 pounds on February 2, 2026, 144.7 pounds on March 3, 2026, and 134.5 pounds on April 8, 2026.
The weight record review revealed that Resident 1 experienced a significant weight loss of 10.2 pounds, or seven percent, within thirty-six days from March 3, 2026, to April 8, 2026. The clinical record failed to reveal evidence that Employee 4, the facility's former Registered Dietitian (RD), timely assessed the significant weight loss when it occurred.
A review of a nutrition/dietary note completed by Employee 4 on April 20, 2026, at 11:54 AM, twelve days after the significant weight loss was identified, documented that Resident 1 continued to have adequate oral and fluid intake, consuming between fifty percent and one hundred percent of meals, and continued to utilize adaptive feeding equipment. The note acknowledged the resident experienced a significant weight loss of 10.2 pounds, or seven percent, from March 3, 2026, to April 8, 2026, but further documented there were no significant weight changes and that the resident's weight remained relatively stable over the previous six months. Employee 4 documented the weight loss was undesirable but related to advanced age and indicated that the February and March weights were "unusually high," contributing to the observed weight loss. The note further indicated there had been no significant changes in meal intake, that current weights were consistent with weights obtained three and six months earlier, and that weight fluctuations could occur due to diuretics (medications used to remove excess fluid from the body). Employee 4 documented that the physician and responsible party were notified, the care plan was reviewed and revised, and the resident would continue to be monitored.
Continued review of Resident 1's weight records revealed the resident weighed 135.7 pounds on April 13, 2026, and 130.7 pounds on April 22, 2026. The resident lost an additional five pounds within nine days. The clinical record failed to reveal evidence that the continued weight loss was timely identified and assessed or that additional nutritional interventions were developed and implemented to address the ongoing decline.
A clinical record review revealed that Employee 5, the facility's RD, completed a nutrition/dietary note on April 30, 2026, at 11:27 AM. The note documented a current weight of 130.7 pounds, a significant weight loss of 7.5 percent in ninety days, continued downward weight trends, and that the resident was at her lowest recorded weight. Although meal intake remained between fifty percent and one hundred percent, Employee 5 recommended initiation of a nutritional juice supplement twice daily to promote weight maintenance.
However, Resident 1's clinical record failed to reveal physician notification or responsible party notification regarding the continued significant weight loss. The clinical record failed to reveal a physician's order for the nutritional juice supplement or evidence that the recommended intervention was implemented.
The facility failed to ensure comprehensive nutrition assessments were completed by an RD to evaluate Resident 1's nutritional and hydration status and develop interventions to address nutritional decline. The facility failed to ensure Resident 1's significant weight losses were timely identified, assessed, and addressed through appropriate nutritional interventions. Additionally, the facility failed to implement the nutritional juice supplement recommended by the RD.
A clinical record review revealed a late-entry dietary note completed on December 29, 2025, documenting that Resident 41 continued on a regular diet with pureed texture and thin liquids and was able to eat mostly independently after staff set-up assistance. The note documented adequate fluid intake and meal intake ranging from twenty-five percent to one hundred percent. The resident also received frozen nutritional supplements and nutritional shakes three times daily with good acceptance. At that time, the Registered Dietitian (RD) documented that the resident's weight had remained relatively stable during the previous six months.
However, a review of the clinical record failed to reveal evidence that an annual comprehensive nutrition assessment had been completed by the RD. The record revealed the last comprehensive nutrition assessment was completed on February 3, 2025.
A review of Resident 41's weight records revealed the following documented weights: 89.2 pounds on February 1, 2026; 80.9 pounds on March 1, 2026; 97.1 pounds on March 6, 2026; and 81.1 pounds on March 12, 2026. The clinical record failed to reveal that reweights were obtained in accordance with facility policy despite the significant fluctuation in recorded weights.
Further review of the weight records revealed Resident 41 experienced a significant weight loss of 8.3 pounds, or 9.3 percent, from February 1, 2026, to March 1, 2026. The March 12, 2026, weight of 81.1 pounds confirmed the resident continued to demonstrate a significant weight loss of approximately nine percent within one month.
A review of a nutrition/dietary progress note completed by Employee 4, the facility's former RD, on March 18, 2026, at 10:55 AM, eighteen days after the significant weight loss was identified, documented that Resident 41 weighed 81.1 pounds and had a Body Mass Index (BMI, a measurement that compares a person's weight to height and is commonly used to assess nutritional status) of 16.9, indicating the resident was underweight. The note further documented that the March 6, 2026, weight of 97.1 pounds was considered an outlier, meaning a value that differed substantially from surrounding weight measurements. Employee 4 documented that the resident experienced a significant weight loss of 9.3 percent in one month and a significant weight loss of 10.8 percent in six months. The note identified the weight loss as undesirable and recommended discontinuing small portions, providing regular portions to promote meal intake, and obtaining weekly weights for two weeks to monitor weight trends.
The clinical record revealed that Employee 4, the facility's former RD, failed to timely assess Resident 41's significant weight loss of 9.3 percent that occurred between February 1, 2026, and March 1, 2026.
Continued review of Resident 41's weight records revealed the resident weighed 81.8 pounds on April 7, 2026, 72.7 pounds on May 1, 2026, 69.2 pounds on May 8, 2026, and 79.6 pounds on May 19, 2026. At the surveyor's request, an additional weight was obtained on May 22, 2026, which recorded the resident's weight as 70.6 pounds.
The clinical record failed to reveal that reweights were obtained in accordance with facility policy to verify the accuracy of the substantial weight fluctuations. Further review revealed that a nutrition/dietary progress note was not completed until May 12, 2026, despite the resident experiencing an additional significant weight loss of 11.1 percent from April 7, 2026, to May 1, 2026, and 15 percent from April 7, 2026, to May 8, 2026.
The facility failed to obtain reweights as required by facility policy to verify the consistency and accuracy of Resident 41's recorded weights. The facility further failed to ensure timely identification, assessment, and intervention for significant weight loss to develop and implement nutritional interventions to address the resident's continued and progressive weight decline.
A review of Resident 28's care plan revealed a nutrition-at-risk care plan was initiated on August 19, 2025. The care plan identified actual or potential nutritional concerns related to osteoarthritis (a condition that causes joint pain and stiffness), generalized muscle weakness, the need for a mechanically altered diet (a diet modified in texture to improve safety with eating), variable meal intake, and a history of significant weight loss. The care plan established goals for the resident to maintain adequate nutritional status, maintain weight, and consume meals as tolerated. Planned interventions included monitoring weights and reporting changes to the physician and Registered Dietitian (RD), providing prescribed diets and nutritional supplements, monitoring and documenting meal intake, completing nutrition assessments quarterly and as needed, and having the RD evaluate the resident and make recommendations as appropriate.
However, a review of the clinical record failed to reveal documented evidence that the facility's RD completed a comprehensive nutrition assessment to evaluate Resident 28's nutritional and hydration status and identify interventions to address nutritional decline.
A review of Resident 28's weight records revealed the resident weighed 108.9 pounds on December 15, 2025, 111.2 pounds on December 19, 2025, 111 pounds on December 26, 2025, 108.8 pounds on January 3, 2026, 92.2 pounds on February 11, 2026, 92.5 pounds on February 13, 2026, and 93.4 pounds on February 18, 2026.
Review of the weight records revealed Resident 28 experienced a significant weight loss of 16.6 pounds, or 15.3 percent, within approximately one month from January 3, 2026, to February 11, 2026.
A clinical record review revealed Employee 4, the facility's former RD, completed a nutrition high-risk/significant weight loss note on February 23, 2026, thirteen days after the significant weight loss had been identified. The note documented that the resident remained on a regular diet with regular texture and thin liquids, had adequate fluid intake, and consumed approximately fifty percent to one hundred percent of meals during the previous thirty days. The note further documented that the resident received high-calorie, high-protein oral nutritional supplements twice daily with documented one hundred percent acceptance according to the Medication Administration Record (MAR), as well as frozen nutritional supplements twice daily with acceptance ranging from fifty percent to one hundred percent. These supplements provided an additional 1,020 calories and 40 grams of protein daily.
Despite these nutritional interventions, Employee 4 documented that the resident's Body Mass Index (BMI, a measurement comparing a person's weight to height that is commonly used to assess nutritional status) was 17.1, indicating the resident was underweight. The note documented that the resident weighed 93.4 pounds on February 18, 2026, 92.5 pounds on February 13, 2026, and 92.2 pounds on February 11, 2026, compared to 108.8 pounds on January 3, 2026, reflecting an unplanned weight loss of 16.6 pounds, or 15.2 percent, within one month. Additional weight comparisons documented a 15.2-pound weight loss over three months from 107.4 pounds on November 4, 2025, and a 31.3-pound weight loss over six months from the admission weight of 123.5 pounds on August 19, 2025.
The note further documented that a weight of 113.3 pounds obtained on November 3, 2025, was considered an outlier, meaning a measurement that differs substantially from surrounding data points. Employee 4 documented that the weight loss was considered questionable due to the resident's reported good meal intake and acceptance of nutritional supplements and initiated weekly weights to evaluate the accuracy and validity of the recorded weights. Although the note documented physician and responsible party notification, the clinical record failed to reveal evidence that the significant weight loss was timely assessed and addressed when initially identified on February 11, 2026.
The clinical record revealed that Employee 4, the facility's former RD, failed to timely assess Resident 28's significant weight loss of 15.3 percent that occurred between January 3, 2026, and February 11, 2026.
The facility failed to ensure completion of a comprehensive nutrition assessment by an RD to evaluate Resident 28's nutritional and hydration needs and develop interventions to address nutritional decline. The facility failed to ensure Resident 28's significant weight loss was timely identified, assessed, and addressed through appropriate nutritional interventions to prevent continued weight loss.
During an interview on May 21, 2026, at 2:25 PM, the Nursing Home Administrator stated that Employee 4 resigned from the facility on April 24, 2026, and that affiliated hospital dietitians were providing coverage for the position. When the above findings were reviewed during the interview, the Nursing Home Administrator confirmed that no additional documentation was available to demonstrate that Resident 28's significant weight loss had been thoroughly assessed by an RD or that interventions had been timely developed and implemented to prevent further weight loss.
28 Pa Code 211.10 (c) Resident care policies.
28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 06/24/2026
Preparation and/or constitution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The registered dietician completed the overdue annual comprehensive nutritional assessments for the identified residents. Findings and recommendations were reviewed with the interdisciplinary team, contributing factors evaluated, and appropriate nutritional interventions were initiated.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The director of nursing/designee conducted an audit of all current residents requiring annual comprehensive nutritional assessments to ensure compliance. Any identified overdue assessments were completed. The registered dietician/designee conducted a facility-wide audit of all residents with significant weight changes within the previous three months. Residents identified with actual or potential nutritional risks received a nutritional review and interventions, if not already in place. The medical records were updated to reflect individualized approaches to maintain or improve nutritional status.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
Education will be provided to the registered dietician regarding regulatory requirements for annual comprehensive nutritional assessments and documentation expectations.
The registered dietician will utilize the Point Click Care tracking tool to identify residents due for annual nutritional assessments. The dietician/designee will evaluate meal intake, preferences, supplements, and nutritional risks.
The registered dietician will provide a list of residents, to the nursing staff, who require greater than monthly weight monitoring.
The effectiveness of interventions will be reviewed by the interdisciplinary team. Residents with significant weight changes will be reviewed at the weekly Risk Meeting, the physician/resident representative will be notified, and interventions will be revised accordingly. Documentation of assessments, physician assessments, interventions, and outcomes will be documented in the resident's medical record.
The registered dietician will monitor residents for weight changes on an ongoing basis and run a Weights and Vitals Exception Report through Point Click Care. The registered dietician will ensure re-weights are completed in a timely manner.
Re-educate charge nurses on the reweight policy and notification of the resident's physician and resident representative. A monthly weight review will be conducted by the registered dietician/designee with implementation of a standardized protocol for notification of the physician, resident representative, and interdisciplinary team when significant weight changes are identified.
How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established?
The administrator/designee will audit assessment completion of records monthly for three months to ensure that annual comprehensive nutritional assessments are completed timely. Audit findings will be validated through the Quality Assurance Performance Improvement (QAPI) program. Additional corrective actions will be implemented as needed. Nutritional interventions may include diagnostic testing, dietary supplements, meal assistance, adaptive equipment, and therapeutic intervention.
Audit all significant weight changes for four weeks, then monthly for three months. Verify appropriate assessments, physician and resident representative notifications, and timely interventions, have been completed. Review audit findings through the Quality Improvement Performance Improvement (QAPI) program monthly for three months. Implement additional corrective findings as necessary based on audit findings.
Dates of when the corrective action will be completed.
6/24/2026
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