§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 review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to monitor and provide appropriate and timely intervention to prevent further weight loss for 1 of 3 residents reviewed. (Resident R1)
Findings include:
Review facility policy on Weight Assessment and Intervention revealed that under section Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain under section policy interpretation and implementation. Under section Weight Assessment: #1. Residents are weighed on admission at intervals established by the interdisciplinary team #3 any weight change of 5% of more since the last weight assessments is retaken the next day for confirmation. #a. If the weight is verified nursing will immediately notify the dietitian. #4. Unless notified of significant weight change the dietitian will review the unit weight record monthly to follow individual weight trends over time. #5. The threshold for a significant and planned and undesired weight loss will be based on the following criteria. #c. 6 months-10% weight loss is significant; greater than 10% is severe. Under section Evaluation: #1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met the evaluation includes: #a. The residents target weight range. #b. The resident's calorie protein and other nutrient needs compared with a resident's current intake. #c. The relationship between current medical condition or clinical situation and recent fluctuations in weight and #d. Whether and to what extent weight stabilization or improvement can be anticipated. #2. The physician and the multidisciplinary team identify conditions and medications that may be causing
anorexia, weight loss or increasing the risk of weight loss.
Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on December 26, 2025, with diagnosis of unspecified Severe Protein Calorie Malnutrition.
Review of Resident R1's Initial malnutrition risk assessment dated December 29, 2025, reveal the resident had severe fat loss severe muscle loss is at risk for malnutrition related to acute and chronic medical conditions.
Review of Resident R1's nutritional risk assessment dated December 29, 2025, revealed that recent weight was 126.6 pounds (December 27, 2025), Under section malnutrition risk: Has moderate decrease in food intake over the last three months due to loss of appetite digestive problems chewing or swallowing difficulties. Under section Assessment and Plan: Resident is at nutritional risk related to acute on chronic medical conditions with low BMI (body mass index) for age, impaired skin integrity and altered texture diet. Under section Recommendations and Plan: Continue Regular Diet, mechanical soft texture, soft bite sized pieces with assistance, thin liquids consistency with diet texture and liquid consistency per SLP (Speech-Language Pathologist) recommendations.
Continued review of the nutritional assessment revealed that the resident's son requested that the resident continued to receive the nutritional supplements Ensure Plus 8 oz. three times a day (350 kcal, 16 gm protein/8 oz.) and Magic Cup 4 oz. twice a day (290 kcal, 9 gm protein/4 oz.) as (he/she) did in the hospital. He also provided resident's food preferences which include hot dogs, french fries, and eggs.
It was also recommended MVI (multivitamins)/Mineral supplement to promote wound healing and weekly weight monitoring x 4 weeks.
Review of Resident R1's care plans dated December 29, 2025, revealed that Resident R1 has a nutritional problem or potential nutritional problem related to acute on chronic medical conditions
including Parkinson's Disease, s/p falls,anemia, severe PCM, metabolicencephalopathy with low BMI (body mass index- a measure of body fat based on height and weight) for age,impaired skin integrity (stage 2 and 3pressure injuries), altered texture diet,significant weight loss x less than onemonth. Goals: Will maintain adequate nutritional status asevidenced by maintaining weight
within 5% of CBW, no s/sx (signs and symptoms) of malnutrition, and consuming at least 75% of at least 3 meals daily through review date. Interventions: Monitor and record intake at meals, obtain weights at ordered intervals, monitor/record/report PRN (as needed) s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month,>7.5% in 3 months, >10% in 6 months. Report abnormal findings to practitioner.Document findings and interventions. (*May be done by Dietitian).
Review of Resident R'1s weight record reveal that on December 26, 2025, Resident R1's weight was 127 pounds; on January 7, 2026, Resident R1's weight was 110 pounds; on January 8, 2026, Resident R1's weight was 113.8 pounds. Further, a re-weigh dated January 8, 2026, revealed that Resident R1's weight was 107 pounds.
Review of the dietician's progress notes dated January 8, 2026, revealed "Nutrition Progress Note and significant weight loss x less than one month, oral intake; mostly 51-75% intake recorded, although resident's son states that resident has been mostly refusing mechanical soft foods. Summary/Recommendations: Resident triggering for unintentional and unfavorable significant 13.4% weight loss within less than one month which may be related to variable per mouth intake with refusal of some meals, increased nutrient demand for wound healing and chronic medical conditions. Resident's son reports that resident's usual weight was about 150 lbs. six months ago based on home health records and states that resident has been having a decline in his weight. Magic Cup from twice a day (BID) to 4 oz. three times a day (TID) with meals (290 kcal, 9 gm protein/4 oz.), adding Fortified Foods TID with meals, adding Prosource 30 ml BID (100 kcal, 10 gm protein/30 ml) and Vitamin C 500 mg BID. Also recommend continued weekly weight monitoring. Nutrition Goals: Nutrient Intake->75% nutrient and hydration needs met Weight Maintenance with no significant weight changes, gradual weight gains favorable.
Review of resident R1's food intake percentage for the month of January 2026 reveal that on January 9, 2026, resident had zero food intake on for breakfast, lunch and dinner. on January 11, 2026, Resident R1 consumed 26-50% of breakfast, 76-100% of lunch and 26-50% of dinner. On January 12, 2026, Resident R1 consumed 26-50% of breakfast and lunch and had zero food intake for dinner. On January 14, 2026, Resident R1 consumed 26-50% of breakfast and dinner and consumed 51-75% of lunch. on January 16, 2026, Resident R1 consumed 26-50% of breakfast, lunch and dinner. On January 17, 2026, Resident had zero food intake for breakfast, lunch and dinner. On January 18, 2026, Resident R1 had zero food intake for breakfast, consumed 51-75% of lunch and 76-100% of dinner. On January 19, 2026, Resident R1 had zero food intake for breakfast and dinner and consumed 76 to 100% of dinner. On January 21, 2026, Resident R1 had zero food intake for breakfast and dinner and consumed 51-75% of lunch. On January 22, 2026, Resident R1 refused breakfast, lunch and consumed 51-75% of dinner. On January 23, 2026, there was no entry for breakfast and lunch and refused dinner.
Further review of Resident R1's clinical record revealed no document evidence that Resident R1 was weighed every week since January 8, 2026, until he was discharged from the facility on January 24, 2026. Further, there was no documented evidence that dietitian conducted further evaluation, monitoring of Resident R1's weight, food and caloric intake, since January 8, 2026, until he was discharged from the facility on January 24, 2026.
Interview with facility Administrator Employee E1 conducted on March 3, 2026, at 10:48AM revealed that the facility did not have a regular dietician at the time and that the facility had just recently hired a full-time dietician.
Interview with full time Dietitian, Employee E3 conducted on March 3, 2026, at 10:50 AM confirmed that there was no further weight taken on Resident R1 after January 8, 2026, further Employee E3 also confirmed that the dietitian did not have any documented evidence of any intervention to address Resident R1's poor appetite.
28 Pa. Code 111.27 Nutritional assessment
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.10(c) Resident care plan
| | Plan of Correction - To be completed: 03/31/2026
1. Resident R1 has since discharged from the facility.
2. Facility has conducted a weight sweep to ensure all residents have accurate weights moving forward.
3. Education of Facility All nursing staff on obtaining weights, documentation of on method of obtaining weights and Meal completion %. Facility Nursing staff educated on Supplement intake on the MAR.
4. RD or designee will conduct Random Audits on weights obtained to ensure patients' weights are completed accurately, Audits will be weekly X 4 weeks and then Monthly X3 months. The results of the audits will be reviewed during the monthly QAPI Committee meeting.
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