§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 clinical record reviews, observations and staff interviews, it was determined that the facility failed to provide nutritional interventions to assure that residents received items to maintain proper weight and health for three of ten residents reviewed (Resident 5, 7, 8).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated June 10, 2026, revealed that the resident was cognitively impaired and dependent on staff for daily care tasks. The resident's care plan, most recently most recently revised June 11, 2026, indicated that the resident was a nutritional risk and that she was to have whole milk with all meals and ice cream with lunch and supper.
A comprehensive MDS assessment for Resident 7, dated April 14, 2026, revealed that the resident is cognitively impaired and dependent on staff for daily care tasks. The resident's care plan, most recently revised on June 16, 2026, indicated that the resident was at risk for malnutrition and that she was to have yogurt with lunch for additional protein.
A quarterly MDS assessment for Resident 8, dated June 1, 2026, revealed that the resident was cognitively impaired and dependent on staff for her daily care tasks. The resident's care plan, dated July 15, 2025, indicated that she was to have ice cream with all meals.
Observations of the lunch meal on July 1, 2026, at 11:46 a.m. until 12:18 p.m. revealed that Resident 5's meal ticket stated she was to have ice cream with her lunch, Resident 7's meal ticket stated she was to have pudding, yogurt, or applesauce with lunch, and Resident 8's meal ticket stated she was to have pudding, yogurt, or apple sauce with every meal. Resident 5 did not have any ice cream served on her lunch tray, Resident 7 did not have any yogurt and Resident 8 did not have any ice cream on her lunch tray. Staff present in the dining room during that time called the kitchen to have the items sent to the dining room. Residents 5 and 8 did not have ice cream after their meal. Resident 7 was asked to stay after she finished her meal to eat some yogurt when it would arrive from the kitchen.
Interview with Licensed Practical Nurse 1 on July 1, 2026, at 11:58 a.m. revealed that the kitchen had not been sending items like yogurt, ice cream, pudding, or apple sauce on the resident's lunch trays. She stated that they used to, but that it stopped and the resident's have not been getting those items. She stated if there is ice cream in the pantry they could give it to the residents, but it is often not stocked.
Interview with Nurse Aide 2 on July 1, 2026, at 11:59 a.m. revealed that the kitchen does not send yogurt, ice cream, or pudding on the resident's trays, even though their tray ticket states they should get it. She stated she will give them something out of the pantry when it is available.
Interview with Nurse Aide 3 on July 1, 2026, at 11:59 a.m. revealed that ice cream has not been coming from the kitchen for any resident for some time now. She stated that sometimes the pantry has ice cream and they can get it from there for the residents if they are still in the dining room when staff are finished feeding other residents.
Interview with the Nursing Home Administrator on July 1, 2026, at 1:00 p.m. revealed that the kitchen had decided not to put the cold ice cream on the warm lunch trays to prevent it from melting. The nursing staff were to provide ice cream from the pantry for the resident. She offered the education that was provided to the staff regarding the change, however, only one of the four staff members that were in the dining room had attended the training and none of them were aware of that change. She further stated that the nursing staff could have given the residents pudding or yogurt from the pantry if those items were stocked there, but they were not stocked in the pantry on July 1, 2026.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
| | Plan of Correction - To be completed: 08/06/2026
Preparation and/ or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions 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.
Residents 5, 7, and 8 were unharmed and given missing from their trays on 7/1/26. No residents were harmed from ice cream or yogurt being provided after the meal rather than on their tray.
All current and new hire dietary team members will be educated by the administrator or designee on comparing the resident meal ticket to their tray to ensure all items on the ticket are on the tray prior to sending the tray to the floor. All current and new hire dietary team members will be educated by the administrator or designee on maintaining a sufficient supply of ice cream, pudding, applesauce, and yogurt in each pantry for all residents requiring these items. All current, agency, and new hire certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurse supervisors (RNs) will be educated by the Director of Nursing (DON) or designee on checking resident meal tickets to ensure no items are missing from a resident's meal tray. All current, agency, and new hire certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurse supervisors (RNs) will be educated by the Director of Nursing (DON) or designee on serving resident ice cream from the floor pantry towards the end of the meal.
The dietary director or designee will audit pantry supply of ice cream, pudding, applesauce, and yogurt three times per week for three weeks, then four times per month for three months. The dietary director or Director of Nursing (DON) or designee will audit 10 served resident meals for inclusion of all items on the resident meal ticket three times per week for three weeks, then four times per month for three months; these audits will include whether ice cream is served, when indicated, during the meal period if not served on the resident tray at the start of the meal. Audits will be reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.
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